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A    MANUAL 


MODERF   SURaERY: 


AN  EXPOSITION  OF  THE  ACCEPTED  DOCTRINES  AND  APPROVED 
OPERATIVE  PROCEDURES  OF  THE  PRESENT  TIME. 

FOR   THE   USE   OF 

STUDENTS  AND  PRACTITIOXERS. 


BY 
JOHN  B.  ROBERTS,  A.M.,  M.D., 

PROFESSOR   OF   St'RGERT   IN   THE   WOMAN'S   MEDICAL   COLLEGE   OF   PENNSYLVANIA;   PROFESSOR   OF 

ANATOMY  AM)   SURGERY   IN    THE   PHILADELPHIA    POLYTLINIC;     LECTURER   IN   ANATOMY 

IN    THE   UNIVERSITY    OF   PENNSYLVANIA. 


WITH  FITE  HUNDRED  AND  ONE  ILLUSTRATIONS. 


PHILADELPH lA: 

LEA    BROTHERS    &    CO. 

18  9  0. 


"^     OUPUCATE    ^ 
iJrCHAHft|5. 


Entered  according  to  the  Act  of  Congress,  in  the  j'ear  1890,  by 

LEA    BROTHERS    Sc    CO., 
in  the  office  of  the  Lil)rarian  of  Congress.     All  riorhts  reserved. 


rraneferreil  trom  the  Liibrary 
0f  OoDgress  under  Seo.  59, 
0*pyrl8-ht  Act  of  Mob.  4,  ISO*. 


DORNAX,      PRINTER. 


THIS  -VOLUME 

IS   INSCKIBED   TO    :MY   FATHER, 

CALEB    C.    ROBERTS, 

TO   WHOSE   LIBERALITY   AND   CARE    I   OWE   EDUCATION   AXD   SUCCESS  ; 

FROM   WHOSE   PRECEPT   AND   EXAMPLE   I   HOPE    I    HAVE 

GAINED   ACCURACY    AND   GOOD   JUDGMENT. 


PREFACE. 


This  treatise  is  the  result  of  au  effort  to  give  the  profession,  in  a  con- 
densed form,  the  accepted  doctrines  and  approved  procedures  of  Modern 
Surgery. 

I  have  endeavored  to  write  a  practical  work,  giving  the  surgical 
principles  and  operative  methods  generally  accepted  and  practised  by 
the  leading  surgeons  of  the  world  at  the  present  time.  The  opinions  of 
the  best  authorities,  the  methods  of  the  most  practical  surgeons,  and  the 
well-established  facts  of  surgical  science  are  discussed ;  but  the  consider- 
ation of  theories,  historical  questions,  traditional  views  and  operations, 
and  innovations  of  undecided  value  has  been  rigidly  avoided. 

The  value  of  an  author's  discretionary  power  in  such  rejection  or 
acceptance  of  material  depends  upon  the  carefulness  of  his  analysis  and 
the  impartiality  and  soundness  of  his  judgment.  It  has  been  my  aim 
to  bring  these  essentials  to  the  work ;  hence,  the  statements  of  the 
volume  represent  my  appreciation  of  the  questions  that  have  presented 
themselves. 

In  order  to  depict  the  present  state  of  modern  surgery  I  have  con- 
sulted standard  text-books  and  current  surgical  literature.  The  best  and 
newest  thought  is  usually  found  in  the  latest  editions  of  monographs ; 
therefore  much  use  has  been  made  of  such  works. 

I  am  indebted  to  my  friend  Dr.  Thomas  S.  K.  Morton  for  writing  the 
sections  on  Diseases  and  Injuries  of  the  Joints,  Diseases  and  Injuries  of 
the  Genito-urinary  Organs,  Dislocations,  Excisions,  Amputations,  and  the 
index.  Without  his  efficient  aid  the  publication  of  the  volume  would 
have  been  greatly  delayed.  Dr.  Morton  and  Dr.  C.  L.  Bower  have  given 
me  much  aid  in  reading  the  proof-sheets  and  in  seeing  the  book  through 
the  press. 

JOHX    B.     ROBERTS. 
1627  Walnut  Street,  Philadelphia. 

September,  1890. 


CONTENTS. 


PART    I. 


CHAPTER  I. 
Inflammation^. 

PAGE 

Definition,  Causes,  Varieties,  Extension  of  Inflammation.  Micro- 
organisms which  are  associated  with  Disease.  Pathology, 
Symptoms,  and  Termination  of  Inflammation    ....         33-49 

CHAPTER  II. 

Destructive  Inflammatory  Processes. 

Suppuration.     Abscess.    Sinus  and  Fistula.     Ulceration.     Ulcers. 

Mortification,  or  Gangrene.     Hospital  Gangrene      .        .        .        50-63 

CHAPTER  III. 

Erysipelas,  Sapr-Emia,  Septicemia.    Pyaemia         .        .        .        64-70 

CHAPTER  IV. 

Scrofula  and  Tuberculosis 71-73 

CHAPTER  V. 
Syphilis 74-83 

CHAPTER  VI. 

EiCKETS  OR  Rachitis .        84-85 

CHAPTER  VII. 

Tumors.    Special  Tumors 86-112 


X  CONTEXTS. 

CHAPTER  VIII. 

PAGE 

Wounds  and  Shock 11 3-1 16 

CHAPTER    IX. 
Mode  of  Repair  and  Treatment  of  Wol'nds        .        .        .     117-125 

CHAPTER  X. 

Practical  Surgery  and  An,f.sthesia 126-132 

CHAPTER  XL 

Operative  Surgery. 

Preparation  of  the  Patient  and  the  Surgeon  and  mode  of  Con- 
ducting Operations.  Control  of  Hemorrhage.  Sulures. 
Dressings.  Bandages.  Counter-irritation.  Abstraction  of 
Blood.     Aspiration  and  Tapping 133-145 

CHAPTER  XII. 
Plaistic  or  Reparative  Surgery 146-152 


PART    11. 

CHAPTER  XIII. 
Surgery  of  Special  Structures. 

Diseases  and  Injuries  of  the  Skin  and  its  Appendages  and  of  the 
Cutaneous  Tissues.  Wart  or  Verruca.  Corn  or  Clavus.  Boil 
or  Furuncle.  Carbuncle.  Lupus.  Arabian  Elephantiasis. 
Burns.  Frostbite  and  Chilblain.  Onychia  or  Onychitis. 
Ingrowing  Toe-nail 153-168 

CHAPTER  XIV. 
Diseases  and  Injuries  of  Muscles,  Tendons,  and  Burs.e. 

Wounds  of  Muscles  and  Tendons.  Dislocation  of  Muscles  and 
Tendons.  Inflammation  of  Tendons.  Deformities  from  Mus- 
cular  Paralysis,   Contraction,   and    Rigidity.      Myotomy   and 


CONTENTS.  XI 

PAGE 

Tenotomy.  Contraction  of  the  Palmar  Fascia  and  its  Digital 
Prolongations.  Thecal  Cyst  or  Ganglion.  Inflammation  of 
Eursse  or  Bursitis,  and  Bursal  Tumors.     Bunion        .         .         .     109-181 

CHAPTER   XY. 

Diseases  and  Injuries  of  the  Xeeve-cextres  and  Xeryes. 

Diseases  and  Injuries  of  the  Brain.  Meningocele  and  Encephalo- 
cele.  Hydrocephalus.  Inflammation  of  the  Brain  from  Surgical 
Causes.  Injuries  of  the  Brain.  Concussion,  Contusion,  and 
Laceration  of  the  Brain.  Compression  of  the  Brain.  Tumors 
of  the  Brain.  Diseases  and  Injuries  of  the  Spinal  Cord.  Hy- 
drorachis  or  Bifid  Spine.  Inflammation  of  the  Spinal  Cord  from 
Surgical  Causes.  Wounds  of  the  Spinal  Cord.  Concussion  or 
Contusion,  and  Laceration  of  the  Cord.  Neuritis,  or  Inflam- 
mation of  Nerves.  Injuries  of  Nerves.  Neuralgia.  Tetanus. 
Hydrophobia.     Traumatic  Delirium  Tremens  ....     182-218 

CHAPTER  XVI. 

Diseases  and  Injuries  of  the  Heart  and  Bloodvessels. 

Wounds  of  the  Pericardium  and  Heart.  Tapping  the  Pericardium 
or  Pericardicentesis.  Diseases  and  Injuries  of  the  Arteries, 
Veins,  and  Capillaries.  Hemorrhage.  Wounds  of  Veins. 
Diseases  of  the  Veins.  Inflammation  of  Veins,  or  Phlebitis. 
Hypertrophy  and  Varicosity  of  Veins.  Diseases  of  Lymph- 
atics. Wounds  of  Lymphatics.  Inflammation  of  Lymphatic 
Vessels  or  Lymphangitis.  Lymphadenitis.  A^aricose  Lymph- 
atic Vessels.  Injuries  and  Diseases  of  Arteries.  Wounds  of 
Arteries.  Traumatic  Aneurism.  Arterio-venous  Wounds  and 
Fistules.  Simple  Arterio-venous  Fistule  or  Aneurismoid  Varix. 
Sacculated  Arterio-venous  Fistule.  Arteritis  and  Degenerative 
Changes  in  Arteries.  Atheromatous  Degeneration  and  Calci- 
fication of  Arteries.  Aneurism.  Ligation  of  Arterial  Trunks 
in  Continuity.  Ligations  of  Special  Arteries.  Arterial  Varix 
or  Varicose  Arteries    .........     219-301 

CHAPTER  XVII. 

Diseases  and  Injuries  of  Bones. 

Periostitis.  Ostitis  or  Osteomyelitis.  Necrosis,  or  Mortification  of 
Bone.  Caries,  or  Tubercular  Ulceration  of  Bone.  Central 
Caries  or  Tubercular  Abscess  of  Bone.  Epiphysitis.  Hyper- 
trophy and  Atrophy  of  Bone.  Osteomalacia.  Softening  of 
Bone.  Tumors  in  Bone.  Injuries  of  Bones.  Fractures. 
Repair  of  Fractures.  Treatment  of  Open  Fractures.  Ununited 
Fractures  or  Pseudarthrosis.  Deformed  or  Vicious  Union  of 
Fractures.  Special  Fractures.  Fractures  of  the  Vertebrse. 
Fractures  of    the  Cranium.      Fractures  of  the   Bones  of  the 


xii  CONTENTS. 

PAGE 

Face.  Fracture  of  the  Nasal  Bones  and  Cartilages.  Fracture 
of  the  Malar  Bone  and  Zygoma.  Fractures  of  the  Superior 
Maxillary  Bone.  Fracture  of  the  Inferior  Maxillary  Bone. 
Fracture  of  the  Hyoid  Bone.  Fracture  of  the  Cartilages  of 
the  Larynx.  Fractures  of  the  Sternum.  Fractures  of  the 
Ribs  and  Costal  Cartilages.  Fractures  of  the  Costal  Cartilages. 
Fractures  of  the  Pelvic  Bones.  Fracture  of  the  Clavicle.  P'rac- 
tures  of  the  Scapula.  Fractures  of  the  Humerus.  Fractures 
of  the  Bones  of  the  Forearm.  Fractures  near  the  Wrist-joint. 
Fractures  of  the  Carpus,  Metacarpus,  and  Phalanges.  Frac- 
tures of  the  Femur.  Fractures  of  the  Shaft  of  the  Femur. 
Fractures  of  the  Patella.  Fractures  of  the  Tibia  and  Fibula. 
Fracture  of  the  Bones  of  the  Foot 302-445 

CHAPTER  XVIII. 

Diseases  and  Injuries  of  the  .Joints,  Cartilages,  and  Ligaments. 

Congenital  Deformities  of  Joints  (Congenital  Dislocations),  Syno- 
vitis. Hemarthrosis.  Arthritis.  Gonorrhoeal  Arthritis.  Tuber- 
cular Arthritis.  Tuberculous  Arthritis  of  Special  Joints. 
Tuberculosis  of  Vertebral  Articulations  (Spondylitis,  Pott's 
Disease).  Tuberculosis  of  the  Sacro-iliac  Articulation.  Tuber- 
culosis of  Hip-joint.  Syphilitic  Arthritis.  Osteo-arthritis 
(Arthritis  Deformans).  Atrophic  Arthritis  (Charcot's  Disease). 
Hysterical  and  Neuralgic  Joint  Affections.  Ankylosis.  Loose 
Bodies  in  .Joints.  Injuries  of  .Joints.  Wounds  of  .Joints.  Dis- 
locations. Treatment  of  Old  Dislocations.  Special  Dislocations. 
Dislocations  of  the  Vertebrae.  Atlo-axoid  and  Occipito-atloid 
Dislocations.  Dislocations  of  the  Dorsal  Vertebrae.  Disloca- 
tions of  the  Ribs  from  the  Vertebral  Column.  Dislocations 
of  the  Coccyx.  Dislocations  of  the  Jaw.  Dislocations  of  the 
Sternum.  Dislocations  of  the  Clavicle.  Dislocations  of  the 
Scapula.  Dislocations  of  the  Humerus.  Downward  or  Sub- 
glenoid Dislocations.  Subcoracoid  Dislocations.  Subclavicular 
Dislocations.  Subspinous  Dislocations.  Conjoint  Dislocations 
of  Radius  and  L'lna.  Divergent  Dislocations  of  the  Radius 
and  Ulna.  Dislocations  of  the  Radius.  Dislocations  of  the 
Upper  End  of  the  Ulna.  Dislocations  of  the  Lower  End  of  the 
Ulna.  Dislocations  of  the  Carpus.  Dislocations  of  the  Meta- 
carpal Bones.  Dislocations  of  the  Phalanges  of  the  Hand. 
Dislocations  of  the  Femur.  Posterior  or  Backward  Disloca- 
tions. Treatment  of  Posterior  Dislocations.  Anterior  or 
Forward  Dislocations.  Old  Dislocations  of  the  Femur.  Dis- 
locations of  the  Tibia.  Dislocations  of  the  Patella.  Disloca- 
tions of  the  Fibula.  Dislocations  at  the  Ankle-joint.  Disloca- 
tions of  the  Various  Bones  of  the  Tarsus.  Dislocation  of 
Cartilages.  Dislocation  of  the  Costal  Cartilages.  Dislocation 
of  the  Ensiform  Cartilage.  Dislocation  of  the  Semi-lunar 
Cartilages.       Operations  upon    Joints.       Excision    of   Joints. 


COISTTENTS.  Xlll 


Excision  of  Temporo-maxillary  Joint.  Excision  of  Shoulder- 
joint.  Excision  of  Elbow-joint.  Excision  of  Wrist-joint. 
Excision  of  Metacarpo-phalangeal,  and  Inter-phalangeal  Joints. 
Excision  of  Hip  joint.  Excision  of  Knee-joint.  Excision  of 
Ankle-joint.  Excision  of  Metatarso-tarsal,  Metatarso-pha- 
langeal,  and  Inter-phalangeal  Joints 446-525 

CHAPTER  XIX. 

Surgical  Diseases  of  the  Eespiratory  Organs. 

Surgical  Diseases  and  Injuries  of  the  Nose.  Foreign  Bodies  in  the 
Nose.  Epistaxis.  Nasal  Catarrh.  Nasal  Polyps.  Adenoid 
Vegetations  in  the  Pharynx.  Deformities  of  the  Nose.  Abscess 
of  the  Antrum.  CEdema  of  the  Glottis.  Fracture  of  the 
Larynx  and  Trachea.  Foreign  Bodies  in  the  Air-passages. 
Tumors  of  the  Larynx  and  Trachea.  Tracheotomy.  Intuba- 
tion of  the  Larynx.  Diseases  of  the  Chest.  Contusions  and 
Abscesses.  Surgical  Treatment  of  Pleural  Effusions.  Pul- 
monary Abscess  and  Gangrene.  Mediastinal  Tumors  and 
Abscesses.  Diseases  of  the  Neck.  Diseases  of  the  Thyroid 
Body.     Bronchocele  or  Goitre 526-551 

CHAPTER  XX. 

Surgical  Diseases  of  the  Mouth. 

Cleft  Palate.  Epithelioma  of  the  Lip.  Tumors  of  the  Mouth. 
Alveolar  Abscess.  Tumors  of  the  Jaw.  Necrosis  of  the  Jaw. 
Diseases  of  the  Tongue.  Inflammation  of  the  Tongue.  Epi- 
thelioma of  the  Tongue.  Diseases  of  the  Tonsils.  Salivary 
Fistule.  Retro-pharyngeal  Abscess.  Diseases  of  the  (Esoph- 
agus. Foreign  Bodies  in  the  Q^^sophagus.  Tumors  of  the 
Qisophagus.  Stricture  of  the  CEsophagus.  Introduction  of 
the  QEsophageal  Bougie  or  Stomach-pump  Tube        .         .         .     552-570 

CHAPTER  XXr. 

Surgical  Diseases  of  the  Abdomen  and  Pelvis. 

Method  of  Operating  within  the  Abdomen  and  Pelvis.  Traumatic 
Peritonitis.  Tapping  the  Abdomen.  Abdominal  and  Pelvic 
Abscesses.  Diseases  and  Injuries  of  the  Stomach.  Foreign 
Bodies  in  the  Stomach.  Wounds  of  the  Stomach.  Operations 
upon  the  Stomach.  Gastrostomy.  Gastrotomy.  Tumors  of 
the  Stomach.  Stricture  of  Gastric  Orifices.  Diseases  and  Inju- 
ries of  the  Intestines.  Foreign  Bodies.  Rupture,  Wounds, 
and  Perforating  Ulcers  of  the  Intestines.  Intestinal  Obstruc- 
tion. Tumors  of  the  Intestines  and  Omentum.  Operations 
on  the  Intestines.  Artificial  Anus.  Appendicitis  and  Typhlitis. 
Colotomy.      Laparo-colotomy.       Resection    of   the    Intestine. 


XIV  CONTEXTS. 

PAGE 

Intestinal  Anastomosis.  Diseases  and  Injuries  of  the  Liver. 
Malignant  Diseases  of  the  I.,iver.  Diseases  and  Injuries  of 
the  Gall-bladder.  Cholecystotomy.  Diseases  and  Injuries  of 
the  Spleen.  Diseases  and  Injuries  of  the  Pancreas.  Di-seases 
and  Injuries  of  the  Uterus  and  its  Appendages.  Tumors  of 
the  Ovary.  Diseases  of  the  Fallopian  Tubes.  Hernia. 
Strangulated  Hernia.  Herniotomy  or  Kelotomy.  Special 
Hernias.  Inguinal  Hernia.  Femoral  Hernia.  Umbilical 
Hernia         ...........      ")7 1-631 

CHAPTER  XXII. 

Surgical  Diseases  of  the  Eectum. 

Pruritus  of  the  Anus.  Inflammation  of  the  Rectum.  Foreign 
Bodies  in  the  Rectum.  Impacted  Feces.  Prolapse  of  the 
Rectum.  Hemorrhoids.  External  Hemorrhoids.  Rectal 
Abscess.  Anal  Fistule.  Recto-vesical,  Recto-urethral,  and 
Recto-vaginal  Fistules.  Anal  Fissure.  Ulceration  of  the 
Anus  and  Rectum.  Stricture  of  the  Rectum.  Malignant  Dis- 
ease of  the  Anus  and  Rectum.     Non-malignant  Rectal  Tumors     G32-G.j4 

CHAPTER  XXIII. 

Surgical  Diseases  and  In.iuries  of  the  Urinary  Orgaxs. 

Diseases  and  Injuries  of  the  Kidney.  Congenital  Malformations. 
Misplacements.  Simple  Misplacement.  Movable  and  P^loating 
Kidney.  Hydronephrosis.  Pyo-nephrosis.  Suppurative  Neph- 
ritis. Peri-nephritis.  Tuberculosis  of  Kidney.  Renal  Calculi. 
Renal  Colic.  Renal  Fistulse.  Tumors  of  the  Kidney.  Injuries 
of  the  Kidney.  Open  Wounds  of  the  Kidney.  Operations 
upon  the  Kidney.  Aspiration.  Nephrorrhaphy.  Nephrotomy. 
Nephro-lithotomy.  Nephrectomy.  The  Ureter.  The  Bladder. 
Congenital  Malformations.  Exstrophy.  Pervious  Urachus. 
Displacements.  Vaginal  Cystocele.  Cystitis.  Acute  Cystitis. 
Chronic  Cystitis.  Tuberculosis  of  the  Bladder.  Vesical  Neu- 
roses. Paralysis.  Atony.  Vesical  Fistuhu.  Sounding  the 
Bladder.  Foreign  Bodies  in  the  Bladder.  Injuries  of  the 
Bladder.  Retention  of  Urine.  Suppression  of  Urine.  Incon- 
tinence of  Urine.  Hematuria.  Pueumo-uria.  Chyluria. 
Operations  upon  the  Bladder.  Aspiration.  Lithotrity.  Tumors 
of  the  Bladder.  Papillomata.  Carcinomata.  Myxomata. 
Vesical  Calculi  (Stone  in  the  Bladder).  Perineal  Cystotomy 
(and  Lithotomy).  Lateral  Perineal  Cystotomy  (and  Lithotomy). 
Median  Perineal  Cystotomy  (and  Lithotomy).  Supra-pubic 
Cystotomy  (and  Lithotomy).  The  Prostate.  Prostatic  Catarrh 
(Prostatorrhcea).  Prostatic  Tuberculosis.  Hypertrophy  of  the 
Prostate.  Tumors  of  the  Prostate.  Prostatic  Calculi.  The 
Urethra.      Congenital   Malformations.      Prolapse   of  Urethra. 


CONTENTS.  XV 

PACK 

Urethritis.  Specific  or  Gonorrhceal  Urethritis  (Gonorrhcea). 
Cowperitis.  Stricture  of  the  Urethra.  Organic  Stricture.  Ex- 
ploration of  the  Urethra.  Dilatation  of  the  Urethra.  Urethral 
Fever.  Urethral  Fistulte.  Calculi  and  Foreign  Bodies.  Tumors. 
Fibro-vascular  Tumors.  Injuries  of  the  Urethra.  Operations 
upon  the  Urethra.  Catheterization.  Catheterization  of  the 
Female.  Internal  Urethrotomy.  External  Urethrotomy.  Di- 
latation of  the  Female  Urethra  ......     655-709 

CHAPTER  XXIV. 

Surgical  Diseases  and  Injuries  of  the  Eepeoductive  Organs. 

The  Scrotum.  Elephantiasis.  Lymph  Scrotum.  Epithelioma. 
Contusions  of  Scrotum.  Wounds.  The  Tunica  Vaginalis. 
Hydrocele.  Hydrocele  of.  the  Spermatic  Cord.  Hydrocele  in 
the  Female.  Hematocele  of  the  Tunica  Vaginalis.  The 
Spermatic  Veins.  Varicocele.  Ligation  of  the  Spermatic 
Veins.  The  Testicle.  Congenital  Abnormalities.  Malposition 
of  the  Testicle.  Epididymitis.  Orchitis.  Tuberculosis  of  the 
Testicle.  Tumors  of  the  Testicle.  Injuries  of  the  Testicle. 
Excision  of  the  Testicle  (Castration).  Spermatorrhoea.  The 
Penis.  Congenital  Abnormalities.  Phimosis.  Paraphimosis. 
Inflammation  of  the  Penis.  Balanitis.  Herpes.  Chancre  and 
Chancroid  of  the  Penis.  Tumors  of  the  Penis.  Papilloma. 
Carcinoma.  Injuries  of  the  Penis.  Excision  of  the  Penis. 
The  Vulva.  Adhesion.  Varix.  Hematoma.  Vulvitis. 
Follicular  Vulvitis.  Inflammation  of  the  Vulvo-vaginal 
Glands.  Destructive  Ulcers.  Chancre  and  Chancroid.  Ele- 
phantiasis. Tumors.  Injuries.  Laceration  of  the  Perineum. 
The  Vagina.  Congenital  Abnormalities.  Retained  Menses. 
Vaginitis.  Chancre  and  Chancroid.  Fistulae.  Tumors. 
Foreign  Bodies.     AVounds .     710-718 

CHAPTER  XXV. 

Deformities,  or  Orthopaedic  Surgery. 

Torticollis,  or  Wry-neck.  Spinal  Curvatures.  Rotary  Lateral 
Curvature,  or  Scoliosis.  Kyphosis.  Lordosis.  Webbed  Fingers. 
Club-foot.  Pes  Varus.  Pes  Valgus.  Pes  Equinus.  Pes 
Calcaneus.     Pes  Planus.     Deformities  of  the  Knee  and  Leg    .     729-742 

CHAPTER  XXVI. 

Amputations. 

Special  Amputations.  Amputation  through  Shoulder-joint,  Am- 
putation of  the  Arm.  Amputation  through  the  Elbow- 
joint.     Amputation    of    the    Forearm.      Amputation    through 


XVI  CONTENTS. 

PAOE 

the  Wrist-joiut.  Inter-carpal  and  Carpo-metacarpal  Amputa- 
tions. Amputation  of  the  Hand.  Amputation  through  the 
Metacarpo-phalangeal  Articulation.  Amputation  of  the  Thumb. 
Amputation  of  Phalanges  of  Hand.  Amputation  through  the 
Hip-joint.  Amputation  of  the  Thigh.  Amputation  through  the 
Knee-joint.  Amputation  of  the  Leg.  Amputation  through  the 
Ankle-joint.  Amputation  through  the  Medio-tarsal  Joint 
(Chopart's).  Amputation  through  the  Tarso-metatarsal  Joint 
(Lisfranc's).     Amputation  through  the  Metatarsus  ,         .        .     743-7G1 

CHAPTER  XXVII. 

Surgical  Diseases  of  the  Breast. 

Diseases  of  the  Mammary  Glands.  Mammary  Neuralgia.  Inflam- 
mation of  the  Breast.  Chronic  Inflammation  of  the  Breast. 
Abscess  of  the  Breast.  Paget's  Disease  of  the  Breast.  Tumors 
of  the  Breast.     Excision  of  the  Breast 762-770 


PART   I. 

GENERAL  SURGICAL  PATHOLOGY,  OR  PRINCIPLES 
OF  SURGERY. 


CHAPTEK    I. 

INFLAMMATION. 

DEFINITION,    CAUSES,    VARIETIES,    EXTENSION    OF    INFLAMMATION. 

Definition.  —  The  process  of  inflammation,  though  of  paramount 
importance  to  the  surgeon  and  the  subject  of  profound  study  and 
observation,  is  not  easily  definable.  Its  elementary  features  are  unknown, 
because  it  is  a  vital  process  which  the  microscope  cannot  study  except  by 
its  results.  Hence,  attempts  to  define  inflammation  are  mere  statements 
of  its  symptoms  and  effects.  The  word  refers  to  the  changes  observed  in 
animal  structure  following  an  injurious  influence  insufiicient  to  cause 
immediate  loss  of  vitality.  This  initial  factor  may  originate  from  with- 
out, extrinsically,  as  a  blow ;  or  from  within,  intrinsically,  as  in  inflam- 
mations due  to  deleterious  elements  circulating  in  the  blood-current. 

Inflammation,  according  to  the  present  condition  of  pathological 
science,  may  be  described  as  a  peculiar  molecular  change  in  the  walls 
of  the  small  bloodvessels,  dependent  upon  an  extrinsic  or  an  intrinsic 
irritation,  which  increases  the  adhesion  of  the  blood  to  the  vessel  walls 
and  allows  permeation  of  the  blood  elements  through  them.  Until  the 
blood  elements  are  allowed  to  escape  by  the  abnormal  permeability  of 
the  vascular  coats,  inflammation  may  be  said  not  to  exist. 

Inflammation  is  not  strictly  a  disease.  It  is  Nature's  reparative  effort 
to  overcome  the  perturbations  caused  by  an  injurious  influence  on  the 
animal  organism. 

There  are  three  terms,  to  which  authors  have  given  somewhat  different 
applications,  that,  on  account  of  their  relationship  to  the  process  of  in- 
flammation, require  explanation  at  this  time.  I  give  to  them  the  definition 
which  seems  most  logical,  in  the  attempt  to  bring  order  out  of  the  exist- 
ing confusion.  Hypercemia  is  an  unusual  amount  of  blood  in  the  vessels, 
due  to  any  cause  whatever.  A  hypersemia  due  to  physiological  causation, 
as  in  glands  during  active  secretion,  in  the  skin  in  blushing,  and  in  erectile 
structures,  is  called  a  determimdion  of  blood.  Hypersemia  resulting  from 
imperfect  venous  return,  due  to  mechanical  pressure  on  veins,  gravity,  or 
diminished  cardiac  power,  is  called  congestion,  which  term  should  be 
employed  only  in  this  restricted  sense.  Hypersemia  produced  by  an 
increased  amount  of  blood  thrown  into  a  part  is  often  denominated 
"active  congestion,"  but  this  tends  to  produce  confusion.     For  practical 


34  INFLAMMATIOX. 

purposes  this  form  of  hyperieiuia  is  the  first  step  toward  inflammation, 
and,  though  often  no  sensible  effusion  occurs,  it  might,  with  considerable 
propriety,  be  styled  inflammatort/  hypenemia. 

Hypercemia  and  inflammation  have  a  close  relationship,  since  hyperiemia 
whether  physiological,  mechanical,  or  active,  if  continued,  leads  to  effusion 
and  exudation,  and  inflammation  at  once  exists.  When  inflammation 
subsides,  hyperemia  is  left  as  the  last  step  toward  restoration  of  the  part 
to  health. 

To  indicate  inflammation  of  a  structure  the  termination  ''itis"  is  added 
to  the  name  indicating  the  structure  aflfected,  as  synovitis,  pleuritis. 

Causks. — The  causes  of  inflammation  are  :  the  exciting  or  determining, 
which  give  rise  to  the  actual  outl)reak  of  inflammation,  and  the  predis- 
posing, which  have  previously  created  a  tendency  that  requires  merely 
an  exciting  cause  to  initiate  the  inflammatory  process.  Exciting  causes 
mav  be  local,  as  in  injuries,  and  constitutional,  as  in  syphilis.  Predis- 
posing causes,  in  like  manner,  may  be  local,  as  in  the  weakness  of  an 
organ  resulting  from  previous  inflammations,  and  constitutional,  as  in 
inherited  or  acquired  impairment  of  bodily  vigor.  A  given  cause  may 
be  at  one  time  an  exciting,  at  another  a  predisposing,  cause.  For 
example,  hyperemia  due  to  increased  functional  activity  of  an  organ  may 
be  the  exciting  cause  of  inflainmation  ;  again,  the  same  hypenemia  of  the 
same  organ  may  be  the  predisposing  cause  to  which  an  irritation,  acting  as 
an  exciting  cause,  must  be  added  to  induce  the  outbreak  of  inflammation. 

Inflammation  due  to  external  injury  is  called  traumatic,  that  without 
definite  assignable  cause  idiopathic.  The  latter  term  must  not  be  under- 
stood as  implying  that  inflammation  can  arise  without  a  cause.  The 
cause  is  always  present,  but  may  elude  our  search.  Inflammation  cannot 
spread  unless  its  cause  has  extended  its  area  of  influence,  nor  can  it  per- 
sist without  a  similar  persistence  of  its  causation. 

In  considering  the  causes  of  inflammation  it  must  be  remembered  that 
there  are  two  factors  in  its  etiology — the  cause  which  exerts  an  exciting 
influence,  and  the  tissue  upon  which  such  influence  is  exerted.  In 
some  cases  the  exciting  cause  acts  without  any  predisposition  of  the  tissue 
being  present,  while,  at  other  times,  the  same  exciting  cause  cannot  pro- 
duce inflammation  unless  the  normal  resisting  power  of  the  tissue  is 
lowered.  This  impaired  resistance  of  the  tissue  may  result  from  either 
an  acquired  or  an  inherited  predisposition.  It  is  seen,  therefore,  that  the 
predisposing  cause  of  inflammation  may  be  anything  which  has  a  ten- 
dencv  to  lower  the  health  of  the  body,  or  the  health  of  any  part  of  the 
body.  Among  causes  which  may  induce  inflammation  there  are  some 
which  are  perfectly  obvious  and  easily  detected.  These  produce  what 
are  often  called  simple  traumatic  inflammations.  Under  this  head  may 
be  included  mechanical  and  chemical  injuries;  injuries  due  to  the  appli- 
cation of  heat  or  cold ;  those  due  to  electricity,  which  causes  electrolysis 
of  the  fluids,  or  to  prolonged  ansemia,  or  bloodlessness,  of  the  part.  Ex- 
cessive functional  activity  and  nervous  influences  are  said  to  produce 
inflammation.  Such  inflammations  do  not  tend  to  spread  beyond  the  site 
originallv  subjected  to  injurious  influences,  nor  to  increase  in  severity 
after  the  application  of  the  exciting  cause  has  ceased.  In  fact,  the 
height  of  the  inflammation  is  reached  soon  after  the  receipt  of  the  injury, 
and  the  inflammation  rapidly  subsides. 

The  irritation  and  consequent  inflammation  produced  by  a  chemical 
agent  does  not,  however,  always  show  itself  at  the  point  at  which  the 
chemical  agent  gains  admission  to  the  body.     Examples  of  this  are  seen 


CAUSES,  35 

ill  instances  of  inflammation  of  the  internal  organs,  such  as  the  kidneys 
and  liver,  produced  by  the  absorption  of  drugs  through  the  skin  or 
stomach.  Alcohol,  for  instance,  produces  chemical  inflammation  of  the 
liver.  Certain  drugs,  on  the  other  hand,  act  injuriously  on  the  kidneys, 
bf  which  organ  they  are  eliminated  from  the  blood.  These  are  instances 
of  inflammation  due  to  chemical  causes,  but  widely  different,  of  course, 
from  the  inflammation  of  the  skin  produced  by  powei'ful  caustics,  where 
the  inflammation  is  produced  at  the  point  of  application  of  the  agent. 

Rheumatic  and  gouty  inflammations  are  perhaps  due  to  a  similar 
action  of  chemical  agents  in  the  blood.  The  inflammations  due  to  what 
is  ordinarily  called  exposure  to  cold  or  wet  are  probably  associated  with 
an  irritation  of  the  vessels,  due  to  driving  the  blood  from  the  surface  of 
the  body  to  the  internal  organs. 

Many  inflammations  whose  causation  was  formerly  obscure,  and  which 
were,  therefore,  called  idiopathic,  are  now  believed  to  be  due  to  the 
presence  of  vegetable  organisms.  These  fungi,  which  are  variously 
called  bacteria,  microbes,  and  microorganisms,  multiply  in  the  fluids  of 
the  human  body,  and  therefore  furnish  continuously  acting  causes.  In- 
flammations resulting  from  these  fungi,  or  microscopic  plants,  may  be 
due  to  the  mechanical  or  chemical  action  exerted  by  them. 

There  is  a  very  great  variation  in  the  severity  or  type  of  inflammation 
due  to  these  organisms  ;  some  of  them  are  very  virulent,  causing  at  once 
gangrene,  others  cause  a  suppurative  inflammation,  and  still  others  a 
chronic  inflammation.  The  variety  of  inflammation  may  be  fibrinous, 
suppurative,  or  productive.  One  of  the  most  important  inflammations 
produced  by  these  fungi  is  that  form  which  is  called  tuberculous.  From 
what  has  been  said,  it  is  easily  perceived  that  these  organisms  have  indi- 
vidual characteristics.  That  form  which  produces  a  certain  disease  can- 
not produce  any  other  disease,  but  such  other  disease  is  caused  only  by 
another  form  of  organism  having  a  different  life  history. 

Again,  there  are  many  organisms  which,  by  entering  the  fluids  of  the 
body,  do  not,  so  far  as  known,  produce  any  form  of  inflammation  or  dis- 
ease. These  are  called  non-pathogenic  organisms  in  contra-distinction  to 
those  above  referred  to,  which  are  called  pathogenic  organisms. 

In  studying  the  microbic,  or  mycotic,  origin  of  inflammation  it  must  be 
remembered  that  the  inflammation  is  not  due  to  the  mere  presence  of  the 
microbes  within  the  body,  because,  under  ordinary  circumstances,  the 
normal  resistance  of  the  tissues  to  pathogenic  processes  prevents  the 
occurrence  of  inflammation.  In  other  words,  bacteria  moving  freely  in 
the  blood-current  may  not  inflame  the  tissues.  Certain  contingencies  are 
requisite  before  their  deleterious  influence  can  be  exerted.  It  is  necessary 
that  the  organisms  shall  be  arrested  so  as  to  be  able  to  multiply  and  pro- 
duce irritation  ;  because,  it  requires  a  large  number  of  these  organisms 
in  the  tissue  to  produce  a  pathogenic  change.  Such  arrest  of  bacteria 
may  be  caused  by  the  processes  of  embolism  or  thro.mbosis,  or  by  injury 
to  a  bloodvessel  by  which  an  extravasation  of  blood  takes  place  into  the 
connective  tissue  surrounding  the  capillary  vessels ;  or  they  may  be 
filtered  out  of  the  lymph-current  by  the  lymph-glands.  These  processes 
which  allow  the  microorganisms  to  come  to  rest  and  settle  may  be  the 
needed  factor  which  shall  cause  the  advent  of  inflammation. 

It  may  occur  that,  notwithstanding  the  ari'est  of  bacteria,  no  inflam- 
mation occurs  because  there  is  no  predisposition  in  the  tissue  at  the  point 
of  arrest,  or,  in  the  general  system  of  the  patient,  to  suflTer  from  microbic 
invasion. 


36  INFLAMMATION 

This  makes  clear  to  us  what  is  meant  in  the  preceding  paragraph  by 
"  predisposing  causes  of  inflammation."  Any  circumstance  which  results 
in  a  depression  of  the  vital  powers,  such,  for  example,  as  the  continued 
abuse  of  alcohol,  or  prolonged  anxiety  and  exhaustion,  may  induce  a 
general  or  constitutional  predisposition  to  inflammation.  Bruises  which 
cause  extravasation  of  blood  may  act  as  a  local  predisposing  cause;  as, 
indeed,  may  any  variety  of  wound.  Wounds  which  are  0{)en  to  the  air, 
by  giving  entrance  to  microorganisms  upon  the  surface  of  the  body  and 
in  the  air,  are  much  more  prone  to  inflammation  than  subcutaneous 
wounds,  since  the  latter  exclude  the  bacteria  which  are  external  to  the 
patient's  body. 

Some  bacteria  will  cause  inflammation  only  when  they  gain  access  to  a 
certain  kind  of  soil  which  is  favorable  for  growth  and  development. 
Portions  of  the  body,  for  instance,  may  be  too  cold  for  their  development, 
in  which  event  inflammation  will  not  occur  or  will  be  arrested.  If,  how- 
ever, these  same  organisms  happen  to  become  located  in  some  part  of  the 
body  which  is  warmer,  they  multiply  and  may  at  once  excite  inflamma- 
tion. This  illustrates  what  has  been  said  before,  that  each  organism  has 
its  peculiarity  which  must  be  accommodated  in  order  to  allow  its  devel- 
opment and  pathogenic  action.  These  microscopic  plants  are  just  as 
particular  as  to  the  kind  of  soil  in  which  they  grow,  and  as  to  the  cir- 
cumstances surrounding  their  growth,  as  are  the  trees  with  which  we 
come  in  contact  in  the  larger  world. 

Certain  conditions  of  the  blood,  such  as  diabetes  and  Bright's  disease, 
are  particularly  favorable  for  the  development  of  certain  forms  of  bacte- 
rial life  and  consequent  inflammations. 

The  occurrence  of  inflammation  depends  upon  other  conditions  than 
those  already  mentioned.  The  species  of  organism  with  which  wounds 
and  tissues  are  affected  is  a  factor  of  imporance.  Some  organisms  are 
much  more  virulent  than  others. 

Again,  the  number  of  organisms  which  gain  access  to  the  tissues  is  a 
matter  of  importance.  It  can  easily  be  understood  that  if  but  a  small 
number  infect  the  animal  or  human  being,  they  can  be  destroyed  or  ren- 
dered inert  by  the  normal  resistance  of  the  tissue.  It  is  known  that  the 
leucocytes  have  a  tendency  to  surround  germs  and  to  enclose  them  so  as 
to  prevent  their  acting  upon  the  tissues.  At  other  times  the  leucocytes 
or  white  blood-cells  appear  to  eat  up  the  bacteria,  and  hence  are  called 
phagocytes.  If,  however,  the  dose  of  pathogenic  organisms  is  very  large, 
or  relatively  large  compared  with  the  resistant  power  of  the  tissues  and 
the  leucocytes,  inflammation  will  be  induced. 

It  is  a  curious  fact  that  the  growth  of  several  organisms  together  may 
induce  inflammatory  results,  which  no  one  of  them  alone  is  capable  of 
eflTecting.  This  is  seen  in  the  harmful  effects  resulting  from  the  associa- 
tion of  putrefactive  organisms  and  pus-causing  organisms.  In  this  in- 
stance it  is  probable  that  the  putrefactive  bacteria  destroying  the  granu- 
lation tissue  which  may  be  present,  allow  the  pyogenic  fungi  to  gain 
access  to  the  general  circulation. 

It  is  believed,  also,  that  some  organisms  act  antagonistically  to  other 
species  of  fungi.  A  patient  inoculated  with  erysipelas  becomes  immune 
to  infection  with  the  anthrax  bacillus. 

The  poison  from  microorganisms  may  be  attenuated  by  certain  labora- 
tory methods  of  handling  the  fungi.  If  they  are  cultivated  outside  of 
the  animal  body,  and  not  passed  through  some  animal  for  a  long  period 
of  time,  they  soon  diminish  in  virulence.     There  are  other  methods  of 


MICROORGANISMS    ASSOCIATED    WITH    DISEASE.         37 

cultivating  these  organisms,  which  in  a  similar  way  weaken  or  attenuate 
the  poison.  It  is  stated  that  the  poisonous  qualities  may  also  be  increased 
by  similar  manipulation  in  the  bacteriological  laboratory. 

Microorganisms  which  are  Associated  with  Disease. 

The  pathogenic  vegetable  parasites  or  fungi  are  of  three  kinds — bac- 
teria, yeasts,  and  moulds.  The  first  are  the  organisms  to  whose  action 
most  of  the  infective  diseases  are  attributed.  The  disease  which  we  call 
thrush,  and  which  is  characterized  by  grayish  patches  forming  upon  the 
mucous  membrane  of  the  mouth  and  adjacent  parts,  is  due  to  a  parasite 
which  is  one  of  the  yeasts.  A  number  of  skin  diseases  are  caused  by  the 
growth  of  pathogenic  moulds.  Favus,  tinea  tonsurans,  tinea  sycosis,  and 
pityriasis  are  instances  of  parasitic  skin  diseases  due  to  moulds.  Actino- 
mycosis is  thought  to  be  due  to  a  fungus  belonging  to  this  class.  It  will 
be  seen,  therefore,  that,  for  the  surgeon,  yeasts  and  moulds  have  little 
interest,  while  the  first  class,  or  bacteria,  are  of  supreme  importance. 

It  should  be  remembered  by  the  student  that  the  word  bacteria  is  used 
very  loosely  by  many  to  refer  to  all  the  kinds  of  parasitic  fungi.  It  is 
better,  however,  to  restrict  it,  as  I  have  done,  to  a  single  class,  to  which 
is  given  the  name  schizomycetes.  Bacteria  are  characterized  by  their 
method  of  multiplication,  which  is  either  by  division,  or  by  the  forma- 
tion of  spores. 

Yeasts,  however,  multiply  by  the  budding  process ;  while  the  moulds 
have  a  more  complicated  method  of  multiplication  or  reproduction,  and 
are  characterized  by  numerous  threads  which  interlace  and  form  the 
mycelium. 

It  is  sufficient  for  our  purpose  to  describe  the  different  forms  of  cells 
which  characterize  the  bacteria.  If  the  cells  are  spherical  or  egg-shaped, 
the  fungus  is  called  a  coccus ;  if  the  cells  are  straight  rods,  the  fungus  is 
called  a  bacillus ;  if  the  rods  are  curved,  the  name  vibrio  is  used  ;  when 
the  plant  assumes  a  more  twisted  form,  it  is  called  spirilla.  These  four 
terms,  then,  are  used  to  give  an  idea  of  the  shape  of  the  plant,  a  single 
cell  of  which  constitutes  an  individual.  These  cells  may  be  grouped 
together  in  various  ways.  If  the  round  or  oval  cells  show  a  tendency  to 
grow  together  in  groups  somewhat  like  bunches  of  grapes,  the  fungus  is 
called  a  staphylococcus,  or  grape-coccus ;  if  the  same  shaped  cells  always 
grow  in  straight  chains,  like  beads  upon  a  string,  the  plant  is  called  a 
streptococcus,  or  chain-coccus  ;  if  there  is  a  tendency  for  two  round  or  oval 
cells  to  keep  close  together,  but  separate  from  other  cells,  the  fungus  is 
called  a  diplococcus. 

These  remarks  make  clear  the  terms  used  to  describe  the  fungi  found 
in  surgical  diseases.  The  streptococcus  pyogenes  is,  in  accordance  with  its 
name,  a  pus-causing  chain-coccus ;  whereas  the  staphylococcus  pyogenes 
is  a  pus-causing  grape-coccus.  There  may  be  several  kinds  of  staphylo- 
coccus or  streptococcus,  each  of  which  has  a  distinctive  adjective  added  to 
its  name.  Thus  we  have  the  white  pus-causing  grape-coccus  and  one  of  a 
golden  color  which  has  a  similar  pathogenic  action. 

In  multiplying,  as  has  been  said,  schizomycetes,  or  fission  fungi,  to 
which  have  been  given  the  name  bacteria,  divide  so  as  to  form  two  or 
more  individual  cells.  Some  of  them,  however,  multiply  by  the  forma- 
tion of  spores,  round  or  oval  bodies,  which  grow  within  or  from  the 
cells,   and  subsequently  become  separate   individuals.      Some   of  these 


38  INFLAMMATION, 

inicroorganisrns  have  the  power  of  motion  and  are  called,  therefore,  motile 
forms.  The  various  form^<  differ  from  each  other  in  the  character  of  food 
which  they  reciuire;  though  carbon,  hydrogen,  nitrogen,  phosphorus, 
sulphur,  niagncs-ium,  and  potassium  are  needed,  probably,  by  all.  The 
presence  of  water  is  necessary  for  the  development  of  fungi ;  therefore, 
thorough  drying  prevents  multiplication  of  fungi,  and,  in  some  cases, 
kills  them.  Some  require  oxygen,  which  others  can  do  without.  The 
temperature  to  which  ihcy  are  exposed  has  also  an  important  bearing  on 
the  life  and  development  of  nearly  all  forms.  They  are  killed  by  boil- 
ing, or  by  a  degree  of  heat  very  little  above  the  boiling-point,  provided 
that  moist  heat  is  used.  Dry  heat  does  not  destroy  them  until  it  reaches 
a  point  considerably  above  the  boiling-point.  The  bacillus  of  malignant 
pustule  is  of  all  pathogenic  microorganisms  the  most  difficult  to  destroy 
by  heat.  Spores  will  resist  a  higher  degree  of  heat  and  more  changes  of 
condition  without  loss  of  vitality  than  will  fully  developed  fungi. 

Bacteria  are  found  in  the  air,  in  the  water,  in  the  earth,  and  upon  the 
external  surface  of  the  human  body.  These  organisms  in  large  numbers, 
both  pathogenic  and  non-pathogenic,  are  found  under  the  nails  and  in  the 
various  folds  of  the  skin,  such  as  the  axilla.  They  are  also  numerous 
upon  the  mucous  membranes  which  come  in  contact  with  the  air,  such  as 
the  bronchial  and  intestinal  mucous  membranes  and  those  of  the  mouth 
and  oesophagus.  In  many  instances  they  do  no  harm,  even  if  pathogenic  ; 
because  of  the  resistance  of  the  tissues  to  their  action,  which  is  great 
when  the  vitality  of  the  tissues  is  unimpaired,  or  because  of  the  com- 
paratively small  number  which  gain  access  to  the  tissues.  Under  favor- 
able circumstances,  however,  multiplication  is  very  rapid,  and  one  indi- 
vidual may  become  many  millions  in  twenty-four  hours. 

It  has  previously  been  stated  that  the  mere  presence  of  pathogenic 
organisms  in  the  blood-current  is  not  sufficient  to  give  rise  to  disease. 
This,  according  to  present  pathological  views,  can  only  occur  when  the 
circumstances  are  favorable  to  their  development  within  the  body,  and 
the  resisting  power  of  the  tissue  to  their  injurious  action  is  imperfect. 

The  antagonism  of  the  tissues  to  microbic  invasion  tends  to  prevent 
disease,  unless  the  number  or  dose  of  infecting  germs  is  too  large  to  be 
successfully  repelled.  The  leucocytes  may  form  a  wall  or  barrier  around 
the  bacteria,  and,  thus  hemming  them  in,  prevent  their  dissemination 
through  the  body;  or  they  may  be  taken  into  the  interior  of  the  leuco- 
cytes and  their  vitality  be  destroyed. 

Varieties. — All  forms  of  inflammation  are  either  acute  or  chronic. 
The  acute  is  rapid  in  course  or  severe  in  symptoms,  the  chronic  slow  in 
progress  or  less  severe  in  symptoms.  It  will  thus  be  seen  that  the  terms 
acute  and  chronic  (perhaps  improperly^  each  contain  two  ideas — one  refer- 
ring to  time,  the  other  to  severity.  The  word  subacute  is  used  to  express 
an  intermediate  severity  between  acute  and  chronic,  but  has  no  reference 
to  time.  Hence  inflammation,  as  to  time,  is  termed  either  acute  or 
chronic  ;  as  to  seventy,  it  is  expressed  as  acute,  subacute,  or  chronic. 

Although  inflammation  is  essentially  the  same  in  whatever  tissue  it 
may  occur,  the  character  of  the  exudate  varies  in  accordance  with  the 
resistance  of  the  tissue,  the  intensity  of  the  injurious  causative  influence, 
and  the  time  of  action  of  that  influence.  These  variations  in  the  exudate 
may  often  be  found  in  the  same  inflammation  by  examining  different 
areas  of  inflamed  structure. 

Serous  Inflammation.  —  In  serous  inflammation  the  exudate  is 
characterized  by  a  small  amount  of  albumin  and  few  leucocytes,  being, 


VARIETIES.  39 

indeed,  very  slightly  different  from  the  normal  transudate  of  healthy 
tissues.  This  fluid  does  not  coagulate.  Instances  of  serous  inflammation 
are  seen  in  pleuritis  with  eff'usion,  arthritis,  hydrocele,  and  in  inflamma- 
tory cedema  of  connective  tissue.  This  form  of  exudate  may  be  expected 
after  slight  or  momentary  injuries,  in  the  early  stages  of  more  severe  in- 
flammations, and  in  cases  where  the  blood  is  impoverished. 

Fibrinous  Inflammation. — Fibrinous  inflammation  gives  rise  to  an 
exudate  containing  larger  quantities  of  albumin  and  more  leucocytes, 
and  hence  more  coagulable.  It  forms,  upon  free  surfaces  and  in  the  sub- 
stances of  organs,  that  which  is  clinically  denominated  "  lymph."  Lymph, 
then,  is  an  inflammatory  product  consisting  of  fibrin  and  entangled  leuco- 
cytes. It  is  sometimes  called  plastic  lymph,  to  show  that  it  is  entirely 
different  from  the  fluid  called  lymph  which  circulates  in  the  lymphatic 
vessels. 

The  best  examples  of  this  form  of  inflammation  are  seen  in  the  serous 
membranes,  such  as  the  peritoneum  and  pleura,  and  in  the  long  continued 
or  chronic  inflammations  of  slight  intensity  in  connective  tissue. 

At  times  we  find  a  grade  of  -inflammation  intermediate  between  these 
forms,  which  may  be  termed  sero-fibrinous  inflammation. 

These  varieties  of  the  inflammatory  process  may  end  by  absorption  of 
the  exudate,  which  is  accomplished  by  the  leucocytes  retux'ning  into  the 
circulation  by  first  entering  the  lymphatic  vessels,  and  by  the  fibrin  and 
some  of  the  leucocytes  undergoing  fatty  degeneration  previous  to  such 
absorption  by  the  lymphatic  system. 

Suppurative  Inflammation. — In  this  very  common  form  of  inflammation 
the  exudate  contains  the  same  elements  as  in  the  fibrinous,  but  does  not 
coagulate.  No  lymph,  therefore,  is  deposited,  or,  if  any  lymph  has  been 
deposited  by  the  previous  form  of  inflammation,  it  is  destroyed  by  the 
accession  of  the  suppurative  stage.  It  is  thus  seen  that  the  so-called 
varieties  of  inflammation  are  rather  stages,  or  degrees,  of  the  process. 
Suppurative  inflammation  is  the  result  of  a  more  irritative  or  longer  con- 
tinued cause  than  the  serous  or  fibrinous  forms. 

Acute  suppuration  is  another  term  signifying  the  same  process.  If  the 
suppuration  is  circumscribed  in  an  abnormal  cavity,  the  resulting  condi- 
tion is  called  abscess  ;  if  diff'used  in  the  tissues,  purulent  infiltration.  Pus 
contained  in  a  normal  cavity,  such  as  the  pleural  sac  or  knee-joint,  is  called 
a  purulent  eflfusion.  If  suppuration  occurs  upon  a  free  surface  of  mucous 
membrane  the  condition  is  called  purulent  catarrh,  provided  the  epithelium 
of  the  mucous  surfaces  is  not  destroyed  ;  while  it  is  called  ulceration  if 
the  epithelium  and  subjacent  tissue  are  destroyed.  Suppuration  attack- 
ing a  cutaneous  surface  also  gives  rise  to  what  is  called  ulceration. 

Productive  Inflammation. — When  the  exudate  of  a  serous  or  fibrinous 
inflammation  becomes  converted  into  new  connective  tissue,  the  inflam- 
mation is  termed  productive,  because  of  the  formation  of  this  new  struc- 
ture. This  process  is  accomplished  by  the  fibrin  disappearing  and 
numerous  leucocytes  coming  into  the  lymph,  after  which  vascular  loops 
from  the  capillary  vessels  of  the  inflamed  structures  penetrate  the  lymph 
and  become  surrounded  by  young  cells.  This  new  tissue,  consisting  of 
capillary  loops  and  young  cells,  which  have  developed  Avithin  the  sub- 
stance of  the  lymph,  is  called  granulation  tissue.  Granulation  tissue  may 
be  converted  into  connective  tissue,  often  called  scar  tissue ;  it  may  de- 
generate into  typical  tubercles  ;  it  may  become  material  looking  like 
pus,  but  which  is  not  true  pus  ;  or  finally,  it  may  actually  break  down 


40  INFLAMMATION, 

into  pus,  the  inflammation  assuming  the  character  of  suppurative  inflam- 
mation, which  it  then  is. 

The  second  transformation  of  granulation  tissue  gives  rise  to  what  is 
variously  called  "chronic"  or  "cold"  abscess  and  chronic  suppuration 
in  bone. 

Modes  of  Extension. — Inflammation  cannot  spread  unless  its  cause 
extends  before  it ;  hence,  inflammations  due  to  mechanical  and  chemical 
irritants  do  not  spread  beyond  the  point  at  which  the  irritation  was  first 
exerted.  All  those  inflammations  which  tend  to  spread  from  the  original 
site  are  probably  due  to  microbie  causes.  It  may  be  taken  for  granted, 
in  accordance  with  the  present  state  of  pathological  knowledge,  that  the 
spread  of  inflammation  is  due  to  vegetable  parasites.  Such  inflammations 
spread  in  three  ways — by  continuity  of  tissue,  by  the  lymph-current,  and 
by  the  blood-current. 

When  inflammation  spreads  by  continuity  of  tissue,  the  bacteria  which 
have  settled  there  are  spread  into  the  surrounding  tissues  by  being  carried 
thither  by  leucocytes  and  by  the  lymph-channels.  This  mode  of  exten- 
sion of  an  inflammatory  process  is  comparatively  limited  in  its  action. 

When  mycotic  inflammation  spreads  by  the  lymphatic  vascular  system, 
the  bacteria  are  carried  along  by  the  current  in  the  lymphatic  vessels 
until  they  reach  the  first  gland,  where  they  are  filtered  out  by  the  ramifi- 
cations which  the  current  makes  in  passing  through  the  interstices  of  the 
gland.  After  being  arrested  thus  they  multiply  and  act  as  an  exciting 
cause  of  inflammation,  producing  in  the  gland  a  secondary  inflammation 
which  is  located  at  a  considerable  distance  from  the  primary  disease.  This 
is  quite  different  from  the  method  of  extension  just  described,  where  the 
fungi  travel  a  short  distance  only  in  the  lymph-current,  or  are  carried 
.short  distances  by  the  white  blood-cells,  choosing,  as  they  do,  the  paths  of 
least  resistance.  The  blood-current  may  carry  bacteria  to  all  parts  of  the 
body,  but  they  are  innocuous,  as  a  rule,  until  they  are  arrested  by  ex- 
travasation, by  clotting  of  the  blood,  or  embolic  plugging  of  the  vessels. 
Under  these  circumstances,  secondary  or  metastatic  inflammation  occurs. 
Pyjemia  is  a  good  example  of  such  metastatic  inflammation.  The  inflam- 
mation of  mumps  being  carried  to  the  breast  and  testicle  is  a  similar 
example  of  metastatic  inflammation. 

Pathology,  Symptoms,  and  Terminations  of  Inflammation. 

Pathology — The  study  of  the  pathological  or  essential  nature  of  in- 
flammation must  be  divided  into  a  consideration  of  the  roles  played  by 
(1)  the  nerves,  (2)  the  small  bloodvessels,  (.">)  the  ])lood,  and  (4)  the 
tissues.  The  changes  occurring  in  each  of  these,  though  in  the  main 
synchronous,  must  be  investigated  separately. 

1.  Serves. — The  agency  of  nerves  is  really  unknown.  The  vaso-motor 
nerves  may  have  a  causative  influence  in  the  dilatation  of  the  vessels,  due 
to  a  reflex  action  following  irritation  of  the  part  affected  ;  but  of  this 
nothing  definite  can  be  asserted.  Recent  researches  show  pretty  conclu- 
sively that  inflammatory  phenomena  depend  on  a  direct  injurious  influence 
upon,  and  a  vital  alteration  of,  the  walls  of  the  bloodvessels,  without  the 
necessity  of  any  direct  nervous  agency. 

2.  Bloodvessels. — As  has  been  previously  stated,  the  essential  factor  or 
lesion  of  inflammation  is  the  change  that  occurs  in  the  walls  of  the  small 
bloodvessels,  bv  which  the  friction  between  the  wail  and  the  blood-current 


PATHOLOGY.  41 

is  increased  and  the  wall  is  made  more  porous.  In  inflammation  of  non- 
vascular tissues,  such  as  the  cornea  and  cartilage,  the  same  vascular 
alterations  take  j^lace  in  the  vessels  which  surround  these  structures,  and 
upon  which  their  nutrition  depends.  The  vascular  phenomenon  of  inflam- 
mation is  dilatation  of  the  arteries,  capillaries,  and  veins  ;  followed  by 
acceleration,  with  subsequent  abnormal  retardation,  of  the  blood-current. 
Mere  acceleration  of  blood-flow  not  followed  by  abnormal  retardation 
does  not  constitute  inflammation,  though  it  may  lead  to  it.  The  dilata- 
tion of  the  vessels  and  the  abnormal  retardation  of  the  current  must  be  per- 
manent. A  preliminary  contraction  of  the  capillaries  is  at  times  seen, 
but  it  is  not  an  essential  factor. 

While  vascular  dilatation  and  blood  retardation  are  being  established, 
the  white  corpuscles  accumulate,  especially  in  the  venules,  and  the  red 
corpuscles  generally  in  the  capillaries,  until  stagnation  or  stasis  of  the 
current  occurs.  This  stage  of  absolute  cessation  of  motion  is  preceded  by 
one  in  which  is  seen  a  mere  oscillation  of  the  vessel  contents  synchronous 
with  the  cardiac  pulsations.  Synchronous  with  these  vascular  changes 
there  occur  permeation  of  the  blood  elements  through  the  vessel  walls  and 
increased  absorption  by  the  lymphatic  vessels. 

3.  Blood. — The  white  corpuscles  (leucocytes)  are  relatively  increased 
in  inflammatory  blood,  and  show  a  tendency  to  keep  near  the  walls  of 
the  vessels.  They  are  less  heavy  than  the  red  corpuscles,  and  hence  are 
thrown  to  the  margin  of  the  blood  stream.  Inflammatory  blood  when 
drawn  shows  more  flbrin  than  non-inflammatory  blood.  This  condition 
of  hyperinosis  and  the  buffy  coat,  formerly  considered  diagnostic  of  in- 
flammation, have  no  diagnostic  or  therapeutic  value.  During  inflamma- 
tion white  cells  migrate  through  the  walls  of  the  venules,  and  red  cells 
are  pressed,  as  it  were,  through  the  walls  of  the  capillaries  into  the  sur- 
rounding tissues.  This  escape  is  supposed  to  occur  through  small  open- 
ings (stomata)  resulting  from  stretching  of  the  walls  of  the  dilated  vessels. 
There  is  no  emigration  from  the  vessels  in  which  absolute  stagnation  has 
taken  place,  nor  from  the  arterioles.  The  escape  of  the  white  corpus- 
cles usually  greatly  exceeds  that  of  the  red,  and  the  vessels  soon  become 
surrounded  and  obscured  by  the  crowd  of  extra-vascular  leucocytes. 
In  intense  inflammations  in  very  vascular  tissues  the  red  escape  in  greater 
numbers  than  the  white  corpuscles,  and  a  resulting  hemorrhagic  spot  is 
visible  to  the  naked  eye.  The  number  of  migrating  cells  is  increased  in 
the  later  stages  of  the  inflammatory  process.  It  is  possible  for  the 
emigrated  leucocytes — (1)  to  be  transformed  into  tissue  cells  ;  (2)  to  re- 
enter the  bloodvessels ;  (3)  to  enter  the  lymphatic  vessels ;  (4)  to  become 
pus-cells. 

There  also  occurs  an  escape  or  exudation  of  fluid  derived  from  the  blood 
liquor  and  similartoit,  which,  when  associated  with  the  escaped  white  and 
red  blood  corpuscles  and  the  pi^oliferating  cells  of  the  inflamed  tissues,  con- 
stitutes the  inflammatory  exudation,  or,  as  it  has  been  termed  by  some 
writers,  inflammatory  lymph  or  fibrin.  The  escaping  fluid  difiers  from 
the  simple  serous  or  dropsical  effusion,  that  occurs  in  congestion  or 
mechanical  hyperasmia,  in  that  it  contains  more  white  corpuscles,  more 
albumin,  and  is  more  prone  to  spontaneous  coagulation.  It  differs  from 
blood  liquor,  or  liquor  sanguinis,  in  having  less  albumin  and  less  coagula- 
bility. I  prefer  to  call  this  inflammatory  fluid  an  exudation  of  lymph,  or 
simply  an  exudate,  and  the  escape  arising  from  venous  distention  a  trans- 
udation of  serum,  or  simply  a  transudate. 

This  exudate  or  inflammatory  lymph  is  of  paramount  importance  to 


42  INFLAMMATION. 

the  surgeon,  for,  by  its  organization  and  transformation  into  tissue  anal- 
ogous to  that  at  the  seat  of  injury  or  disease,  hemorrhage  is  prevented, 
wounds  united,  abscesses  circumscribed  and  limited,  plastic  surgery  made 
possible,  and  other  reparative  surgical  processes  accomplished.  At  times, 
however,  it  produces  morbid  conditions,  strictures,  and  adhesions,  alters 
structure  by  interstitial  deposit,  and  is  exceeding  destructive  to  functional 
integrity. 

It  is  well,  it  seems  to  me,  to  apply  the  term  exudate,  or  lymph,  to  effusions 
occurring  from  inflammation,  even  when  they  closely  resemble  the  serous 
transudate  of  mechanical  venous  obstruction.  The  milder  forms  of  in- 
flammation give  rise  to  a  fluid  containing  so  little  albumin  and  having  so 
little  tendency  to  coagulation  that  it  is  impossible  to  distinguish  it  from 
the  fluid  of  a  non-inflammatory  dropsy.  If,  however,  inflammation  exist, 
let  this  be  called  lymph  ;  if  inflammation  does  not  exist,  call  it  a  transu- 
date or  serum. 

On  mucous  or  serous  surfaces  the  exudate  is  readily  seen  during  the 
progress  of  inflammation  ;  in  some  tissues  it  is  exhibited  as  swelling;  in 
the  cornea  and  other  non-vascular  structures  it  is  found  surrounding  the 
part,  because  it  is  the  adjacent  vessels  which  present  the  inflammatory 
alterations.  Theblood  pJienomenaof  hiftammation,  then,  are  niir/raiion  and 
ezudution. 

4.  Tissues. — The  tissues  are  swollen  and  infiltrated  with  the  escaping 
blood  elements,  and  the  proper  cells  of  the  tissue  involved  show  disordered 
nutrition,  such  as  coagulation-necrosis  and  fatty  degeneration.  The  im- 
pairment of  nutrition  may  result  in  the  formation  of  inferior  tissue,  sup- 
puration, or  gangrene.  The  peptonizing  action  of  microorganisms  has 
to  do  with  the  inflammatory  destruction  of  tissue,  and  thus  aids  the 
malign  influence  of  the  chemical  and  physicalchanges  wrought  by  original 
injury  and  the  deluging  of  the  tissues  with  escaping  blocd-elements. 
AVithin  the  tissues  there  is  proliferation  or  multiplication  of  the  white 
blood-cells  which  have  escaped  from  the  vessels ;  but  multiplication  of 
the  proper  or  native  cells  of  the  tissue  does  not  take  ])lace,  except  when 
repair  or  regeneration  of  tissue  is  going  on  coincident  with  inflammation 
of  only  moderate  intensity.  This  proliferation  must  not  be  considered  as 
a  part  of  the  inflammatory  process.  During  inflamn)ation  the  tissue  ele- 
ments are  obscured  by  the  intermingled  white  corpuscles  and  filaments  of 
fibrin  ;  and  the  structures  are  changed  in  physical  consistence,  being 
sometimes  softer  than  normal,  at  other  times  harder. 

The  tissue  alteration  of  inflammation,  then,  may  be  described  as  dis- 
turbance of  nutrition,  associated  ^vith  proliferation  of  white  blood-cells. 

The  phenomena  of  inflammation  may  finally  be  thus  formulated  : 

1.  Nerves:   Unknown,  or  possibly  vaso-motor  influences. 

2.  Bloodvessels:  Permanent  dilatation  of  calibre  associated  with  per- 
meability of  walls. 

3.  Blood:  Permanent  abnormal  retardation  cf  current  associated  with 
migration  and  exudation. 

4.  Tissues  :  Disturbances  of  nutrition  associated  with  proliferation  of 
white  blood-cells.  It  was  formerly  held  that  the  native  or  tissue  cells 
also  underwent  proliferation. 

Symptoms. — The  local  symptoms  of  inflammation  are  those  exhibited 
at  the  point  at  which  the  process  is  going  on  ;  the  constitutional  or  general 
symptoms  are  manifested  by  the  patient's  organism  as  a  whole  and  are 
observable  in  functional  derangement  of  the  various  organs  without  any 
necessary  relation  to  the  situation  of  the  inflammatory  changes.     The 


SYMPTOMS.  43 

general  symptoms  imply  an  existing  inflammation,  but  do  not  indicate  its 
locality. 

The  local  symptoms  are  pain,  discoloration,  swelling,  heat,  and  disordered 
function.  It  requires  the  co-existence  of  a  number  of  these  abnormal 
manifestations  to  constitute  inflammation,  and  one  or  more  may  be 
prominent  or  entirely  absent,  according  to  the  variety  of  the  inflammation 
and  the  nature  of  the  inflamed  tissue. 

Pain  is  a  subjective  symptom  of  inflammation,  while  the  other  manifesta- 
tions are,  for  the  most  part,  really  objective  physical  signs.  The  pain  of 
inflammation  is  due  to  pressure  of  the  exudate  on  nerve-endings  and 
possibly  to  chemical  irritation  exerted  upon  them ;  is  persistent ;  is  in- 
creased by  motion  and  the  dependent  position  ;  and  must  be  distinguished 
from  the  paroxysmal  pain  of  neuralgia  and  spasm.  Its  severity  depends 
more  upon  the  tissue  aifected  than  the  degree  of  inflammation,  and  is 
often  inverse  to  the  amount  of  swelling  possible,  because  the  pressure  of 
the  distended  vessels  and  exudate  upon  the  nerve  filaments  is  increased 
when  the  structures  are  too  dense  to  allow  swelling.  Pain  may  be  reflected 
by  nervous  distribution  to  a  part"remote  from  the  seat  of  disease,  as  occurs 
in  coxalgia ;  in  such  cases  it  is  not  strictly  a  local  symptom.  Throbbing 
pain,  which  is  due  to  increased  tension  at  each  pulsation  of  the  heart,  is 
usually  indicative  of  the  advent  of  suppuration. 

The  discoloration  usually  varies  from  the  shades  of  red,  the  usual  hue, 
to  those  of  purple  and  blue.  It  is  essential  that  the  alteration  in  color  be 
permanent,  for  the  transient  hypertemia  of  merely  physiological  causation 
also  produces  redness.  In  the  cornea,  arachnoid,  and  similar  non-vascular 
structures  the  change  is  manifested  by  a  whitish  opacity  and  a  loss  of 
lustre,  Avhile  the  surrounding  vascular  tissues  present  the  usual  inflam- 
matory redness.  In  iritis  there  is  a  loss  of  lustre  and  a  brownish  dis- 
coloration. 

The  blackness  of  gangrenous  tissue  and  the  whiteness  of  necrotic  bone 
have  been  erroneously  instanced  as  illustrations  of  inflammatory  altera- 
tion of  color,  but,  since  inflammation  ends  at  the  moment  death  of  tissue 
occurs,  these  are  not  strictly  inflammatory  discolorations.  The  cause  of 
the  red  discoloration  in  inflammation  is  the  abnormal  amount  of  blood  in 
the  vessels,  and,  perhaps,  at  times,  a  real  staining  of  the  tissues  by  the 
coloring  matter  of  the  corpuscles.  As  resistance  to  flow  of  blood  increases 
because  of  change  in  wall  of  vessels  and  pressure  from  exudate,  the  parts 
become  bluish,  or  mottled  and  pale. 

The  temperature  of  an  inflamed  part  is  usually  increased.  It  is  fre- 
quently above  100^  F.  There  is  no  production  of  heat  at  the  inflam- 
matory focus,  but  the  increase  is  due  to  the  increased  rapidity  of  the 
arterial  circulation.  A  local  increase  of  heat  in  chronic  inflammation 
may  be  impercej^tible  ;  hence,  for  example,  we  speak  of  "  cold"  abscesses. 

Inflammatory  swelling  is  due  to  the  increased  amount  of  blood  in  the 
vessels  and  to  the  migration  and  exudation  which  occur.  If  the  exudate 
consists  principally  of  fluid  the  part  is  said  to  be  (Edematous ;  and  a  de- 
pression made  in  the  surface  by  pressure  of  the  surgeon's  finger  is  apt  to 
remain  for  a  few  moments  as  a  little  pit.  This  "pitting"  does  not  show 
if  the  tissues  are  tensely  stretched.  It  is  most  typical  in  oedema  from 
mechanical  hyper^emia.  Usually  the  exudate  is  cellular  rather  than 
fluid  and  the  swollen  tissues  are  too  hard  to  pit.  Swelling  is  always 
great  in  those  parts,  such  as  the  scrotum,  formed  largely  of  loose  con- 
nective tissue,  because  there  is  less  resistance  to  the  escape  from  the 
vessels  of  inflammatory  products.    In  dense  resisting  structures  and  under 


44  INFLAMMATION. 

tense  fascite  much  swelling  is  impossible ;  and  hence,  great  pain  is  exper- 
ienced during  inflammation  in  such  localities.  The  tissue-pressure  thus 
induced  may  lead  to  gangrene  by  totally  obstructing  circulation,  if  not 
relieved  by  tree  incisions  to  allow  escape  of  fluids  and  to  relax  distended 
structures.  The  occurrence  of  swelling  is  frequently  beneficial  by  dimin- 
ishing the  intravascular  pressure.  If  the  exudate  is  small  in  quantity  and 
the  lymphatics  carry  it  off,  no  swelling  will  exist.  This  occurs  in  slight 
grades  of  inflammation. 

Disordered  function  is  a  symptom  (sometimes  subjective  and  sometimes 
objective)  always  present, and  attracts  attention  when  the  other  manifesta- 
tions of  inflammation  are  more  or  less  in  abeyance.  The  increased  or 
impaired  sensibility  of  the  sense  organs;  the  irritability  of  the  hollow 
viscera  ;  the  modihed  secretions  of  the  various  glands  ;  and  the  alteration 
of  nutrition,  shown  by  defective  absorption,  by  atrophy  and  hypertrophy, 
are  all  well-known  instances  of  functional  disturbance  arising  from  in- 
flammation. The  injury  inflicted  upon  every  tissue  by  the  morbid  process 
readily  explains  the  functional  disturbance. 

Tlie  general  or  constitutional  symptoms  of  inflammation  are  grouped 
together  and  called  inflammatory  or  symptomatic  fever,  because  the  in- 
crease of  the  general  bodily  temperature  is  such  a  characteristic  member 
of  the  group.  The  terms  traumatic  fever  and  surgical  fever  are  some- 
times employed  as  synonyms  of  iuflammatoi\v  fever  when  the  inflamma- 
tion is  due  to  an  injury.  Inflammatory  fever  varies  with  the  intensity, 
extent,  and  locality  of  the  process,  and  with  toxic  influences  associated 
with  it,  and  is  practicallv  absent  in  slight  inflammations  of  unimportant 
localities  and  when  microbic  infection  of  the  blood  is  })revented.  It  de- 
pends on  the  presence  in  the  blood  of  products  of  the  morbid  tissue- 
change  occurring  at  the  seat  of  inflammation,  or  of  poisonous  principles 
manuftictured  at  the  seat  of  injury  by  microorganisms  of  a  vegetable 
nature.  The  most  important  duty  of  the  surgeon  is  to  protect  all  acci- 
dental or  operation  wounds  from  infection  by  these  vegetable  parasites, 
which,  under  the  general  name  bacteria,  enter  the  blood-stream  and 
are  believed  to  be  responsible  for  all  grave  degrees  of  inflammatory 
fever.  Inflammatory  fever,  in  other  words,  is  usually  a  poisoned  condi- 
tion of  the  blood  due  to  microorganisms.  Inflammatory  fever  becomes 
prominent  within  twenty-four  hours  after  the  incipiency  of  the  local 
symptoms.  There  are  two  types  of  constitutional  disturbance  in  inflam- 
mation :  the  sthenic,  representing  excess  of  force ;  the  asthenic,  repre- 
senting want  of  force.  The  irritative  type,  so-called,  is  not  a  special 
form,  as  all  ca.ses  are  necessarily  either  sthenic  or  asthenic.  The 
respiratory,  circulatory,  digestive,  nervous,  secretory,  and  other  gen- 
eral symptoms  accompanying  inflammation  show  modiflcations  accord- 
ing to  the  type  of  the  constitutional  disturbance  ;  hence,  as  the  treatment 
must  greatly  vary  in  the  two  conditions,  the  necessity  of  an  early  recogni- 
tion of  the  type  is  evident.  The  constitutional  symptoms  of  inflammation, 
when  asthenic,  resemble  those  of  typhoid  fever  ;  hence,  they  are  often 
said  to  belong  to  the  "  typhoid  condition." 

The  student  must  remember,  however,  that  typhoid  or  enteric  fever  and 
the  "  typhoid  condition,"  though  presenting  similar  symptoms,  are  dif- 
ferent entities. 

The  following  table  shows  the  differential  diagnosis  of  typical  cases  of 
sthenic  and  asthenic  inflammatorv  fever: 


TREATMENT.  45 

Sthenic.  Asthenic. 

Patient  ....     Usually  of  vigorous  constitution.     Previously   of  weak   constitution, 

though  may  have  been  vigorous. 

Pulse Full,  bounding,  90-120.  Compressible,  weak,  120-160. 

Respiration      .     .     Oppressed,  hurried.  Shallow  (?),  hurried. 

Digestive  organs .     Constipation,    loss    of   appetite.     Bowels    irregular,      tendency     to 
white  furred  tongue,  thirst.  diarrhoea,  loss  of  appetite,  brown 

and  dry  tongue,  sordes,  thirst. 

Skin Dry  and  hot,  temperature   100°-     Often   clammy,   temperature   99°- 

105°,  chill  at  beginning.  101°,     chills     and     colliquative 

sweats. 
Urine      ....     Scanty,  highly  colored,  uric  acid     No  marked  difference  from  sthenic 

abundant,  chlorides  diminished.       type. 
Nervous  system    .     Restless,    headache,   active    de-     Stupor,  not  much  headache,  mut- 

lirium.  tering  delirium. 

Muscular  system.     Pain  in  back  and  limbs.  Twitching  of  tendons. 

Terminations. — There  can  be  but  two  terminations  of  inflammation. 
First,  gradual  return  of  the  tissues  to  health  without  destruction  of  their 
elements  and  functions ;  and  second,  death  of  these  tissues,  which  may 
take  place  molecularly  or  in  masses  large  enough  to  be  readily  seen. 
When  inflammation  terminates  in  the  first  manner  the  walls  of  the  blood- 
vessels are  restored  to  their  normal  condition,  the  deposits  absorbed  and 
the  damaged  tissues  regenerated.  Resolution  is  then  said  to  have  taken 
place.  In  the  second  instance,  if  death  occur  violecularly,  that  is,  if  small 
particles  die,  it  is  called  ulceration  if  in  soft  tissues,  and  caries  if  in 
bone ;  while  death  in  mass  of  soft  parts  is  termed  gangrene ;  of  bone, 
necrosis.  It  should  be  observed  that  pathologists  apply  the  term  necrosis 
to  all  forms  of  tissue-death,  whether  in  bone  or  soft  structures,  in  mass  or 
in  small  particles. 

When  the  surface  of  an  inflamed  mucous  membrane  suffers  death  and  is 
covered  with  a  gray,  yellowish  or  reddish  membrane,  which  is  tough  and 
adheres  to  it,  the  inflammation  is  said  to  be  of  a  diphtheritic  character. 
Such  gangrenous  inflammations  occur  on  the  conjunctiva  or  any  other 
mucous  membrane,  and  may  attack  wounds.  They  are  infective  inflam- 
mations and  take  their  name  from  the  disease  diphtheria,  which  often,  but 
not  always,  gives  rise  to  a  pharyngeal  inflammation  of  this  character. 
Xot  all  diphtheritic  inflammations,  however,  are  diphtheria.  These  mem- 
branes differ  clinically  from  the  layer  of  lymph  which  ordinarily  forms  on 
inflamed  surfaces  by  the  great  difficulty  with  which  they  are  detached. 

The  results  or  sequences  of  inflammation,  such  as  newly  organized 
tissue,  adhesions,  eff'usions,  exudations,  pus,  sloughs,  and  sequestra  must 
not  be  confounded  with  its  terminations.  It  can  only  terminate  either  in 
a  return  to  health  of  the  tissues  inflamed  or  in  the  death  of  the  same. 
The  parts  in  the  vicinity  may  continue  in  a  state  of  inflammation,  but  the 
death  of  tissue,  by  either  ulceration  or  gangrene,  eflfectually  terminates 
the  inflammatory  process  in  that  particular  issue. 

Resolution  is  the  termination  of  inflammation  which  the  surgeon  ordi- 
narily aims  to  secure,  but  in  many  instances  it  is  impossible  to  obtain  it, 
and  suppuration,  ulceration,  or  gangrene  occurs.  Hence,  after  considering 
the  treatment  to  be  pursued  in  the  endeavor  to  obtain  resolution,  I  shall 
discuss  suppuration,  ulceration,  and  gangrene. 

Treatment. — The  most  important  precept  that  can  be  taught  in  rela- 
tion to  the  management  of  inflammation  is  this:  Inflamed  structures  tend 
to  recovery  as  soon  as  the  cause  of  inflammation  is  removed.  Hence, 
when  the  surgeon  can  remove  the  cause  the  rest  of  the  treatment  consists 
in  merely  waiting  for  the  reparative  efforts  of  nature,  and  in  averting  any 
secondary  irritative  action  that  may  supervene.     When  the  obscurity  of 


46  INFLAMMATION. 

the  cause  precludes  its  reuioval,  efforts  must  be  made  to  avert  the  advance 
and  the  destructive  effects  of  the  inflammation,  until  the  cause  ceases  to  be 
operative. 

The  indications  of  treatment  in  all  ctises  of  inflammation,  then,  are  to 
remove  the  cause  and  to  establish  resolution  as  promptly  as  possible. 

Removal  of  the  cause  is  to  be  effected  on  general  rational  principles : 
for  example,  a  foreign  body  is  to  be  extracted  from  the  tissues  ;  the  patient 
himself  is  to  be  transported  from  unfavorable  surroundings  ;  or,  if  the 
cause  lie  in  some  vitiated  state  of  the  blood,  remedies  to  remove  that 
state  are  to  be  administered.  Attempts  to  remove  the  cause  are  not  justi- 
fiable, however,  if  they  render  the  patient  liable  to  conditions  more  dan- 
gerous to  life  than  that  for  which  he  is  being  treated,  for  it  must  always 
be  remembered  that  the  surgeon  is  treating  a  condition  rather  than  an 
entity. 

Resolution,  if  possible,  is  to  be  induced  by  local  and  constitutional 
measures.  The  latter,  of  course,  includes  hygienic  and  dietetic  as  well  as 
medicinal  agencies.  After  injuries  and  operations  the  surgeon  desires 
the  presence  of  reparative  inflammation  to  heal  the  wounds,  and,  there- 
fore, little  is  required  except  attention  to  prevent  the  occurrence  of  inor- 
dinate inflammatory  action.  The  prevention  and  arrest  of  raicrobic 
infection  of  wounds  is  the  most  important  duty  of  the  surgeon  in  this 
connection.  The  means  by  which  these  ends  are  to  be  accomplished  will 
be  discussed  under  Treatment  of  Wounds. 

The  local  treatment  of  inflammation  is  properly  discussed  before  the 
constitutional,  because  many  cases  of  minor  severity  demand  no  constitu- 
tional treatment  whatever.  Inflammation  is  treated  locally  by  (1)  posi- 
tion and  functional  rest;  (2)  cold;  (3)  heat;  (4)  anodynes;  (o)  blood- 
letting; (0)  diminishing  arterial  supply;  (7)  antiseptics  and  necrotics; 
(8)  stimulants  and  astringents;  (9)  counter  irritation ;  (10)  compression 
and  friction. 

Position  and  functional  rest. — Rest  from  functional  activity  and  that 
position  which  renders  afflux  of  blood  to  the  part  most  difficult  are 
essentials  in  treating  inflammation,  especially  when  acute.  Elevation 
and  immobility  of  the  parts  are,  therefore,  usually  to  be  enforced,  sup- 
plemented in  many  cases  by  confinement  to  bed. 

Cold. — The  depressant  and  sedative  action  of  cold  is  utilized  as  a  pre- 
ventive of  inflammation,  and,  in  the  earliest  stages  of  the  process,  to  limit 
its  severity.  It  should  not  be  employed  when  suppuration  or  mortifica- 
tion is  to  be  feared,  nor,  as  a  rule,  in  chronic  inflammation.  Cold  and 
moisture  may  be  applied  by  cold  baths,  rapidly  evaporating  lotions,  or 
by  irrigation  in  which  a  constant  application  of  water,  simple  or  medi- 
cated, is  maintained  by  allowing  it  to  drop  on  cloths  laid  over  the  inflamed 
part.  Dry  cold  is  obtained  by  using  tubes  or  rubber  bags  filled  with 
cold  water  or  ice. 

Heat. — Heat  is  practically  always  combined  with  moisture,  because  all 
warm  applications  soon  become  saturated  with  secretions  from  the  skin. 
Hot  dressings  are  properly  used  when  there  is  pain  and  tension,  a  tendency 
to  suppuration,  and  a  probability  of  mortification.  They  aid  in  mortifying 
processes  by  causing  separation  of  the  sloughs,  thus  promoting  the  suppura- 
tive action  beneath  the  dead  tissue.  Heat  is  usually  indicated  when  cold 
is  contra-indicated.  It  may  ba  obtained  by  local  baths  of  hot  water  or 
steam,  fomentations,  poultices,  etc. 

Any  warm  or  hot  application  combined  with  moisture  acts  as  a  poul- 
tice if  evaporation  be  prevented  by  rubber  cloth,  waxed  paper,  or  other 


TREATMENT.  47 

impervious  covering.  The  protracted  use  of  heat  is  objectionable  because 
it  causes  relaxation  of  tissue.  When  suppuration  is  inevitable  deep 
incision  is  preferable  to  poultices,  because  it  relieves  pain  promptly,  pre- 
vents destruction  of  tissue,  and  hastens  cure.  It  is  probable  that  the 
value  of  moist  heat  is  largely  due  to  its  increasing  the  migration  of  white 
blood  cells,  which  thus,  by  their  numbers,  become  more  powerful  in  their 
antagonism  to  the  microorganisms  causing  the  inflammation. 

Anodynes. — The  narcotics,  especially  the  preparations  of  opium  and 
belladonna,  are  frequently  beneficial  by  relieving  the  pain  of  inflamma- 
tion. Extract  of  belladonna,  softened  with  water  and  smeared  over  the 
surface,  and  opium  combined  with  acetate  of  lead  ai'e  favorite  prescriptions. 

Local  bloodletting. — The  direct  abstraction  of  blood  from  engorged 
vessels  and  the  opportunity  of  escape  afforded  deposits  infiltrating  the 
tissues  are  the  means  by  which  puncture,  scarification,  incision  and  wet 
cupping  act  as  potent  agencies  in  combating  inflammation.  At  times  it 
is  not  practicable  to  incise  the  vessels  and  tissues  of  the  inflamed  organ, 
and  then  wet  cupping  or  leeching  at  an  adjacent  point  is  done  to  relieve 
the  hypersemic  structures.  As  a  rule  the  bloodletting  should  be  applied 
at  the  focus  of  inflammation,  and  the  bleeding  encouraged  by  warm  appli- 
cations. The  advantage  of  incision  over  poulticing  has  been  mentioned 
previously. 

Cutting  off  arterial  supply. — This  is  done  be  applying  pressure  upon, 
or  by  ligating  in  its  continuity,  the  main  artery,  and  thus  diminishing 
the  supply  of  blood  to  the  inflamed  member.  Ligation  has  seldom  been 
resorted  to,  except  experimentally ;  but  intermittent  digital  pressure  or 
partial  compression  by  compresses  is  occasionally  judiciously  employed  as 
a  prophylactic  measure  after  operations  on  the  extremities. 

Antiseptics  and  necrotics  are  adapted  to  the  treatment  of  wounds,  and 
are  usually  employed  as  prophylactics  to  prevent  excessive  inflammation 
liable  to  occur  from  pyogenic  or  putrefactive  bacterial  infection  or  from 
inoculation  of  animal  poisons. 

The  use  of  carbolic  acid,  corrosive  sublimate,  beta-naphthol,  and 
similar  agents,  will  be  described  in  discussing  the  antiseptic  treatment 
of  wounds.  The  most  efiicient  necrotics  to  prevent  absorption  of  the 
poison  of  hydrophobia,  snake-bites,  etc.,  are  the  actual  cautery,  strong 
nitric  acid,  and  acid  nitrate  of  mercury.  Immediate  excision  is  prefer- 
able when  it  can  be  adopted. 

Stimidants  and  astringents. — These  local  remedies,  of  which  nitrate  of 
silver  and  acetate  of  lead  are  examples,  occupy  a  high  rank  in  the  treat- 
ment of  inflammation,  especiallj^  of  mucous  membranes.  The  more 
chronic  the  inflammation  the  stronger  must  be  the  stimulant  and  astrin- 
gent impression. 

Counter-irritation  is  applied  at  a  point  more  or  less  remote  from  the 
inflammatory  focus,  and  varies  in  degree  from  mere  redness  of  the  skin 
to  vesication,  suppuration,  and  complete  destruction  of  the  skin  as  by  the 
actual  cautery.  Except  in  the  mildest  form,  as  obtained  by  sinapisms, 
counter-irritation  is  seldom  used  in  acute  inflammation.  It  probably  acts 
by  abstracting  blood  from,  and  lessening  the  textural  excitability  of,  the 
inflamed  organ. 

Compression  and  friction. — Compression,  by  means  of  muslin  or  elastic 
bandages  or  adhesive  strips,  and  friction,  or  manipulation  (massage), 
either  with  or  without  oils  and  liniments,  are  most  eflBcient  means  of 
relieving  muscular  spasm  and  of  producing  absorption  of  deposits  in 
chronic  and  the  late  stages  of  acute  inflammation. 


48  INFLAMMATION. 

Constitutional  Treatment. — The  general  or  con^^titutional  manage- 
ment of  iaHammation  comprises:  1.  Abstraction  of  blood  by  vene- 
section. 2.  Increase  of  secretion  and  elimination  by  cathartics,  dia- 
phoretics, diuretics,  and  emetics.  3.  Diminution  of  vascular  tension  by 
cardiac  depressants.  4.  Increase  of  vascular  tone  by  tonics  and  stimu- 
lants. 5.  Decrease  of  nervous  excitement  by  anodynes.  6.  Reduction 
of  temperature  by  antipyretics  and  the  general  application  of  cold.  7. 
Correction  of  morbid  conditions  of  blood  by  alteratives  and  specifics. 
8.  Regulation  of  sanitary  surroundings  and  diet. 

These  measures,  however,  as  well  as  the  local  means,  are  not  all  to  be 
employed  in  each  instance  of  inflammation,  for,  while  some  are  appro- 
priate to  the  sthenic  type,  others  are  adapted  to  asthenic  cases.  More- 
over, it  is  to  be  remembered  that  many  medicinal  agents  have  a  com- 
bination of  activities,  being,  at  the  same  time,  evacuants,  anodynes,  and 
cardiac  depressants  ;  hence,  one  or  two  remedies  will  often  meet  all  the 
requirements. 

Venesection. — In  the  early  stages  of  acute  sthenic  inflammation,  when 
the  after-depression  from  loss  of  blood  will  be  less  detrimental  than  the 
threatened  destruction  of  the  integrity  of  a  vital  organ,  general  blood- 
letting is  beneficial.  Venesection  acts  mechanically  by  lessening  the 
amount  of  blood  in  the  system,  and,  therefore,  relieves  inflammatory 
engorgement,  which  may  be  the  most  disastrous  factor  of  the  inflamma- 
tory process  demanding  treatment.  This  is  especially  true  of  pulmonary 
and  cerebral  inflammations.  Vascular  engorgement,  however,  is  the 
result,  not  the  cause  of  inflammation,  and  removal  of  blood  is  not  re- 
moval of  inflammation.  Venesection  should  never,  as  a  rule,  be  employed 
when  the  pulse  is  feeble  and  frequent  and  the  symptoms  those  of  asthenia, 
nor  when  it  is  probable  from  the  activity  of  the  inflammatory  attack,  as 
in  blood-poisoning,  that  depression  will  shortly  follow. 

Cathartics,  diaphoretics,  diuretics,  and  emetics,  are  internal  remedies  of 
value ;  because  they  increase  glandular  secretion,  which  is  arrested  in  in- 
flammatory fever,  act  as  derivatives  by  attracting  blood  to  other  organs, 
deplete  by  drawing  away  the  watery  constituents  of  the  blood,  expel 
irritating  substances  from  the  system,  and  have  a  refrigerant  or  cooling 
eff^ect. 

Depressants. — Aconite,  veratrum  viride,  and  antimony  are  the  cardiac 
sedatives  most  frequently  employed  to  reduce  the  high  vascular  tension, 
exhibited  by  the  full,  bounding,  frequent  pulse  of  acute  inflammation 
occurring  in  robust,  plethoric  persons.  They  are  selected  when  the  de- 
pressing influence  of  venesection  is  considered  unwarrantable. 

Tonics  and  f<tinndants. — Asthenic  inflammations,  on  the  other  hand, 
require  from  the  first,  quinia,  iron,  digitalis,  alcohol,  and  highly  nutri- 
tious food,  to  increase  cardiac  power  and  sustain  life  under  the  depressing 
effects  of  the  inflammatory  process.  The  same  remedies  are  usually 
needed  after  the  subsidence  of  active  sthenic  symptoms,  which  leave  the 
patient  emaciated  and  exhausted  by  the  severity  of  the  structural  changes 
that  have  taken  place. 

Anodynes. — Pain,  restlessness,  and  general  nervous  excitability  call  for 
the  administration  of  opiates,  chloral,  the  bromides,  sulfonal,  hyoscin, 
and  kindred  drugs,  to  give  physiological  and  functional  repose.  The 
beneficial  effect  on  inflammatory  fever  of  a  few  hours'  profound  sleep  is 
familiar. 

Cold. — Sponging  the  surface  of  the  body,  cold  packs,  and  cold  baths 
are   certainly   effectual    in   diminishing    bodily    temperature,    and    are 


CONSTITUTIONAL    TREATMENT.  -^9 

employed  advantageously  in  inflammatory  affections.  Antipyrine,  anti- 
febrin,  and  similar  drugs  with  a  known  ability  to  lower  the  general 
temperature  are  often  valuable  remedies. 

Alteratives  and  specifics. — Certain  inflammatory  lesions  are  best  com- 
bated by  specific  remedies,  which  have  some  alterant  or  eliminating 
blood  action  and  which  should  be  given  as  soon  as  the  diagnosis  is  estab- 
lished. As  examples  may  be  mentioned  mei'cury  and  the  iodides  in 
syphilitic  inflammations,  quinia  in  malarial,'  and  colchicum  in  gouty 
lesions.  Mercury,  because  of  its  supposed  antiplastic  action,  was  long 
given  in  all  inflammations  to  lessen  the  deposition  of  lymph,  but  this 
belief  has  deserv^edly,  I  think,  lost  ground.  The  removal  of  inflamma- 
tory products  in  chronic  conditions  is  certainly  effected  by  the  so-called 
sorbefacients,  among  which  the  preparations  of  mercury,  iodine,  and 
ammonium  chloride  stand  preeminent. 

Sanitary  and  dietetic  measures. — Cleanliness  of  person  and  of  surgical 
dressings,  freedom  from  microbic  and  deleterious  atmospheric  influences ; 
regulation  of  the  temperature  of  the  room ;  proper  ventilation ;  freedom 
from  noise  and  anxiety;  good  nursing  and  judicious  diet  are  more  im- 
portant than  any  one  requirement  heretofore  mentioned  under  the  consti- 
tutional treatment  of  inflammmation.  Acute  sthenic  cases  may  require 
some  restriction  of  diet,  but  not  the  starvation  treatment  of  past  genera- 
tions of  surgeons.  Asthenic  inflammation  invariably  requires  concen- 
trated, easily  digestible  food  at  frequent  intervals. 

In  conclusion,  a  recapitulation  of  the  differential  therapeutic  indica- 
tions of  sthenic  and  asthenic  and  of  acute  and  chronic  inflammations 
may  be  instructive. 

Sthenic  cases  present  symptoms  of  overaction,  and  require  depleting, 
depressant,  and  non-stimulant  remedies,  with  restricted  diet. 

Asthenic  cases  present  symptoms  of  depression,  and  require  corrob- 
orant, tonic,  and  stimulant  remedies,  with  abundance  of  nutritious  food. 

Acute  inflammations,  being  either  sthenic  or  asthenic,  require  treat- 
ment according  to  their  type,  with  depleting  and  soothing  applications 
locally. 

Chronic  inflammations,  being  usually  more  or  less  asthenic  in  type  and 
characterized  by  much  inflammatory  deposit,  require  tonic  and  alterative 
treatment,  with  stimulating  applications  locally. 


CHAPTER    II. 

SUPPURATION. 

Mention  of  suppurative  inflammation  has  been  made  in  a  previous 
section,  but,  so  important  is  the  relation  of  the  suppurative  process  to 
operative  surgery  and  surgical  pathology,  that  it  is  necessary  to  consider 
a  little  more  fully  the  clinical  history  of  this  pathological  condition. 

Suppuration,  or  the  formation  of  pus,  is  due  to  causes  which  are  sufficiently 
intense  and  sufficiently  prolonged  in  their  action  to  give  rise  to  suppura- 
tive inflammation,  and  which  have  the  peculiarity  of  preventing  the 
formation  of  fibrin  in  the  inflammatory  exudate.  According  to  present 
pathological  views,  it  is  believed  that  the  yellow  liquid  called  pus,  laud- 
able pus  according  to  the  older  writers,  never  occurs  except  when  vege- 
table fungi  are  present.  In  some  other  cases  there  is  a  liquid  found  which 
is  often  called  pus,  but  which  is  not  true  pus.  This  kind  of  fluid  is  found 
in  so-called  chronic  abscesses,  in  bone  abscesses,  and  under  other  circum- 
stances. It  is  preferable  to  call  it  a  puriform  licjuid,  and  restrict  the 
term  pus  to  the  creamy  discharge  that  escapes  from  acute  abscesses  and 
ulcerated  surfaces. 

Let  it  be  understood,  then,  that  for  the  clinical  purposes  of  the  surgeon 
pus  never  occurs  except  in  association  with  microorganisms,  and,  therefore, 
does  not  occur  in  inflammation  of  a  simple  traumatic  kind,  unless  the  seat 
of  the  inflammation  becomes  infected  with  fungi.  There  are  about  twelve 
vegetable  parasites  which  are  known  to  cause  the  formation  of  pus  ;  those 
most  frequently  found  are  the  staphylococcus  pyogenes  aureus,  the 
staphylococcus  pyogenes  albus,  and  the  streptococcus  pyogenes.  The 
first  two  are  grape  coccusses,  w-hile  the  streptococcus  is  a  chain- 
coccus;  the  two  former  usually  produce  circumscribed  suppuration  and 
abscess,  while  the  streptococcus  is  usually  the  cause  of  spreading  and 
diffuse  suppuration. 

The  importance  of  this  connection  between  organisms  and  suppuration 
is  very  clear,  because  it  indicates  at  once  that  great  care  must  be  taken  to 
prevent  infection,  in  simple  traumatic  inflammations,  with  germs  from  the 
hands  of  the  surgeon,  his  instruments,  or  dressings. 

Pus  is  a  yellow  or  greenish-white,  alkaline  fluid,  presenting  character- 
tistics  varying  with  the  peculiarities  of  the  inflammation  producing  it. 
It  consists  of  a  liquid  in  which  float  white  corpuscles.  The  pus  liquor  is 
composed  of  water,  albumin,  fj^ts,  and  salts,  and  is  derived  from  the  blood, 
with  the  liquid  portion  of  which  it  seems  to  be  almost  identical.  It  con- 
tains, however,  the  pus-forming  microorganisms  and  their  chemical 
products.  The  corpuscles  are,  in  fjict,  the  migrated  leucocytes  referred  to 
in  the  section  on  the  pathology  of  inflammation,  which  have  now  lost 
their  vitality.  Some  of  them  are  still  capable  of  changing  their  shape 
and  migrating,  and  are  considered  to  be  the  white  blood  cells  which  have 
just  escaped  from  the  vessels.  As  usually  seen  under  the  microscope  the 
corpuscles  are  dead,  and  have  lost  the  amoeboid  movements  of  the  living 
cells. 


ABSCESS.  51 

Pus  has  a  tendency  to  cause  liquefaction  and  disintegration  of  the 
tissues  with  which  it  comes  in  contact.  It  may  itself  occasionally  be 
absorbed  after  fatty  metamorphosis,  or  be  changed  into  a  caseous  mass ; 
as  a  rule,  however,  if  not  evacuated  by  operation  it  is  discharged  through 
an  opening  produced  by  its  disintegrating  action  on  the  overlying  tissues. 
It  may  be  secreted  from  a  free,  unbroken  surface,  as  in  inflammation  of 
mucous  membrane,  and  constitutes  most  of  the  discharge  in  all  cases  of 
ulceration. 

Varieties. — When  a  granulating  surface  in  a  healthy  person  is  pro- 
gressing favorably  toward  cicatrization  the  pus  secreted  is  of  a  creamy 
consistence,  and  has  a  specific  gravity  of  about  1030,  yellow  color,  and 
little  or  no  odor.  These  features,  therefore,  pertain  to  what  was  formerly 
called  healthy,  or  laudable  pus.  The  so-called  vmhealthy  pus  is  fre- 
quently, though  not  always,  thin,  of  low  specific  gravity,  of  a  dirty  yellow 
or  reddish  color,  and  has  often  an  ofiensive  smell,  and  a  tendency  to  irri- 
tate the  skin.  It  is  termed  ichorous,  or  sanious  pus.  Other  adjectives 
are  used  to  describe  various  conditions  and  appearances  of  pus ;  thus 
curdy,  gummy,  scrofulous,  sanguinolent,  contagious  pus,  and  muco-pus  are 
terms  often  heard,  but  most  of  them  are  indefinite  and  unscientific.  At 
the  present  time  the  occurrence  of  pus  is  believed  to  be  due  to  infection 
of  the  wound  by  microorganisms ;  hence  no  pus  can  be  called  healthy. 
Wounds,  however  severe,  will,  if  kept  free  from  organisms,  heal  without 
pus. 

Tests. — Pus  mixed  with  other  fluids  can  be  detected  by  the  addition  of 
solution  of  potassa,  with   which  it  forms  a  gelatinous  mass.     This  and 
other  tests,  however,  are  inferior  to  microscopic 
examination,  which  discloses  the  characteristic  Fig.  i. 

spheroidal    semi-transparent   corpuscles,  from  «  f, 

3  5^0  0^^  to  o-jVoth  of  an  inch  in  diameter,  con-      ^.^     ^  (^ 

taining  granules  and  nuclei.     The  nuclei  are      "^       .,.  ^,     ^^ 

made  more  distinct  by  the  addition  of  dilute  '^  ^     ^^ 

acetic  acid.  Some  of  these  corpuscles  are  iden-  Pus  corpuscles  as  seen  after 
tical  in  appearance  with  white  blood-cells,  and  death:  «,  before,  h,  after  the 
are  the  w'hite  cells  which  have  just  escaped  addition  of  acetic  acid.  X400. 
from  the  vessels.  (Green.) 

Microscopic  examination  with  suitable  illu- 
mination and  sutficiently  high  oil-immersion  lenses  will  bring  to  light  the 
microorganisms  to  whose  presence  the  suppurative  action  is  due. 


Abscess. 

Definition. — An  abscess  is  often  described  as  a  collection  of  pus  cir- 
cumscribed by  a  wall  of  lymph,  or  as  an  abnormal  cavity  containing 
pus ;  while  suppuration  occurring  within  the  meshes  of  the  connective 
tissue  without  such  limiting  wall  is  cviWedi  a,  purulent  infiltration,  and  Si 
secretion  of  pus  from  a  mucous,  serous,  or  granulating  surface,  a,  purulent 
effusion. 

These  distinctions  are  frequently  ignored,  however,  for  a  "  diflTused  " 
abscess  is  an  impossibility  if  abscess  means  a  circumscribed  cavity  filled 
with  pus  ;  and  certainly  the  expression,  "  abscess  of  the  knee-joint,"  is 
more  common  than  "  purulent  eSusion  in  the  knee-joint."  It  would  be 
less  confusing  to  define  an  abscess  simply  as   a  cavity  containing  pus, 


52  SUPPURATION. 

without  any  restrictions  as  to  a  limiting  wall  or  to  the  nature  of  its  sur- 
roundings. There  is  certainly  no  etymological  objection  to  this  use, 
which  is  certainly  in  accordance  with  the  ordinary  signification  of  the 
word.  The  symptoms,  diagnosis,  and  local  treatment  of  pus  in  the 
normal  sacs  and  cavities,  as  the  pleural  cavity  and  knee-joint,  and  in 
newly-formed  spaces  in  the  connective  tissue  are  the  same ;  and  they  are 
practically,  in  both  cases,  abscesses. 

Varieties.  Acute  abscess. — When  pyogenic  organisms  are  arrested 
in  the  tissues  they  multiply  and  cause  coagulation-necrosis  in  the  cells. 
To  prevent  the  injurious  effects  of  these  organisms  a  large  number  of 
leucocytes  appear  in  the  region  affected,  and,  by  their  endeavor  to  prevent 
encroachment  of  the  microorganisms  upon  other  tissues,  form  a  wall 
around  the  group  of  germs. 

The  antagonism  between  the  organisms  and  the  leucocytes  is  kept  up 
until  the  wall  of  granulation  tissue  cx'eated  by  the  action  of  the  white 
blood-cells  is  too  dense  for  the  microorganisms  to  penetrate.  It  is  thus 
that  the  suppurating  focus  is  circumscribed ;  within  this  wall  the  tissue 
cells  break  down,  and  under  the  peptonizing  influence  of  the  micro- 
organisms the  formation  of  fibrin  in  the  exudate  is  prevented.  The 
cavity  of  the  abscess,  therefore,  contains  dead  leucocytes,  microorganisms, 
and  their  chemical  products,  and  destroyed  tissue  cells,  in  addition  to  in- 
flammatory exudate.  These  constituents  make  up  the  creamy  liquid 
which  is  called  pus. 

The  tendency  of  the  pus  contained  in  this  cavity  is  to  soften  the  sur- 
rounding tissue  and  to  spread  in  the  direction  of  least  resistance  until  it  is 
discharged  through  an  opening  upon  a  free  surface.  This  is  called  the 
pointing  or  spontaneous  opening  of  an  abscess.  Such  a  spontaneous 
opening  relieves  the  tension,  which  has  been  one  of  the  causes  of  the 
continuance  of  the  inflammation,  and  permits  the  pus  and  microorgan- 
isms to  be  evacuated.  The  collapse  of  the  walls  of  the  abscess  and  the 
adhesion  of  the  opposite  surfaces  readily  complete  the  cure,  if  the  admis- 
sion of  putrefactive  bacteria  is  prevented. 

In  the  event  of  putrefaction  taking  place,  suppuration  continues  for  a 
comparatively  long  time,  according  to  the  situation  and  the  character  of 
the  abscess.  Healing  of  the  abscess  may  be  hastened  by  the  surgeon  o{)en- 
ing  the  cavity  and  evacuating  its  contents  long  before  the  pus  reaches 
the  surface ;  but,  in  this  event,  it  is  equally  important  that  the  operation 
should  be  done  antiseptically,  since  the  admission  of  putrefactive  and 
pyogenic  germs  would  keep  up  the  inflammation  and  the  suppuration,  as 
it  Avould  after  spontaneous  evacuation. 

Very  rarely  the  pus  of  an  acute  abscess  may  become  encapsulated  and 
undergo  caseation  or  calcification  ;  the  mass  in  a  sort  of  sac  may  then 
remain  in  the  tissue  as  an  innocuous  tenant  for  many  years,  though  it 
forms  a  spot  of  least  resistance  at  which  inflammation  may  readily  be  set 
up  at  any  future  time. 

Diff'used  suppuration  frequently  occurs  and  causes  what  is  often 
called  difiised  abscess.  The  process  is  of  similar  pathological  nature 
to  that  just  described,  but  the  pus  is  not  enclosed  in  a  distinctly  limited 
cavity.  The  condition  is  due  to  a  more  intense  inflammation,  and  is 
usually  believed  to  be  due  to  the  presence  of  the  pyogenic  strepto- 
coccus, which  has  a  more  intense  peptonizing  influence  on  the  cells  than 
the  mycotic  causes  of  such  suppurations  as  are  limited  by  a  distinct  barrier 
of  cells.  Sloughs  and  shreds  of  gangrenous  tissue  are  often  found 
commingled  with  the  pus  of  diffused  suppuration. 


ABSCESS.  53 

The  acute  or  phlegmonous  abscess  necessarily  corresponds  in  sj^mptoras 
with  acute  inflammation,  of  which  it  is  a  result.  The  advent  of  suppur- 
ation in  the  progress  of  acute  inflammation  is  often  marked  by  rigors  and 
great  constitutional  disturbance;  after  which  the  throbbing  local  pain, 
the  shining  red  skin,  and  the  acuminated  appearance  indicate  that  an 
abscess  is  being  formed.  The  pus  usually  produces  softening  of  structure, 
and  tends  to  escape  toward  a  free  surface.  The  consequent  elevation  of 
the  overlying  tissues  is  distinctive  of  an  abscess  about  to  point,  and,  as 
the  skin  becomes  thin  over  the  advancing  pus,  the  characteristic  yellow 
color  becomes  apparent,  after  which  a  small  slough  is  separated,  leaving 
an  orifice  through  which  the  pus  is  discharged.  The  walls  of  the  abscess 
then  collapse,  and  the  cavity  is  filled  up  like  an  ulcer  by  the  granulating 
process ;  in  fact,  an  abscess  within  the  tissues  has  been  called  a  "  closed 
ulcer."  Deep  abscesses  may  produce  .very  little  change  upon  the  surface, 
except  a  localized  oedema. 

Metastatic  abscesses  are  essential  elements  of  pyaemia,  and  will  receive 
consideration  under  that  heading. 

The  so-called  chronic  or  cold  abscess,  which  is  probably  usually  a  lesion 
of  tubercular  inflammation  and  is,  therefore,  slow  in  progress,  does  not 
exhibit  very  active  local  symptoms.  It  is  apt  to  occur  in  connection 
with  bones  and  lymphatic  glands  and  in  persons  of  the  so-called  scrofulous 
habit,  but  may  be  found  in  any  region  and  in  any  patient.  There  is  no 
heat  of  skin,  little  or  no  cutaneous  redness,  no  pain,  and  generally  no 
tendency  to  pointing.  The  skin  becomes  thin  over  the  puriform  collec- 
tion and  an  orifice  by  which  the  contents  escape  may  form  after  a  long 
time ;  but,  instead  of  the  pointed  elevation  of  an  acute  abscess,  there  is 
seen  a  general  rounded  protrusion  of  thin  and  purplish  integument. 
The  puriform  liquid  is  confined  by  a  thick  wall,  forming  a  tough  sac  lined 
with  velvety  elevations,  and  is  usually  thin  in  consistence,  containing 
cheesy  masses,  ill-formed  corpuscles,  and  cholesterin  crystals.  It  is  not 
pus  in  the  strict  sense,  and  should  be  discriminated  from  that  which  is 
found  in  acute  abscesses.  Chronic  or  tubercular  abscesses  often  become 
very  large,  because  they  do  not  tend  to  spontaneous  evacuation.  If  we 
do  not  consider  the  fluid  in  these  so-called  chronic  abscesses  to  be  pus,  and 
it  certainly  differs  from  pus,  the  term  abscess  is  inappropriate.  The  term, 
however,  is  still  retained  because  of  its  convenience. 

Diagnosis. — Acute  abscesses  are  diagnosticated  by  the  history  of  pre- 
ceding acute  inflammation,  the  superficial  oedema,  the  throbbing  pain,  the 
appearance  of  pointing,  the  sense  of  fluctuation,  and  in  cases  of  doubt  by 
the  use  of  an  exploring  needle  or  by  the  withdrawal  of  some  of  the  pus 
with  a  hypodermic  syringe  or  aspirator.  Chronic  abscesses  are  distin- 
guished by  the  absence  of  symptoms  pointing  to  aneurism,  cystic  tumors 
or  malignant  growths,  by  the  negative  history,  the  possibly  depraved 
constitution  of  the  patient,  oedema,  fluctuation,  and  by  aspiration. 
Fluctuation  is  the  wave  caused  by  the  displacement  of  fluid  when  pressure 
is  suddenly  made  upon  the  swelling.  It  shows  the  existence  of  liquid 
contents,  but  gives  no  indication  of  their  character.  It  may  be  obtained 
by  placing  the  fingers  of  the  two  hands  on  opposite  sides  of  the  suspected 
abscess  and  making  intermittent  pressure  or  striking  sudden  taps.  In 
small  collections  it  is  better  to  grasp  the  swelling  between  the  thumb  and 
fore-finger  of  one  hand,  and  make  the  parts  tense,  while  intermittent 
pressure  is  made  by  the  fore-finger  of  the  other  hand.  The  transmission 
of  the  impulse  proves  that  the  contents  are  fluid,  but  other  symptoms 


54  SUPPURATION. 

must  be  investigated  to  determine  whether  pus,  soruni,  or  hlood  is  con- 
tained in  the  tumor. 

The  opcninixof  an  abscess  must  always  l)e  an  aseptic  ])rocedure.  After 
the  incision  the  interior  of  the  sac  sliould  be  thorouj^hly  scraped  out 
with  a  curette  and  made  perfectly  aseptic  by  means  of  irri<:ation.  This 
removes  all  pus  and  microorganisms.  The  cavity,  if  small,  may  then  be 
sewed  uj)  so  as  to  bring  the  walls  together  and  allow  healing.  If  the 
abscess  he  a  large  one  it  may  be  needful  to  provide  for  drainage  by  the 
use  of  drainage-tubes.  This  is  especially  necessary  in  large  cavities  that 
cannot  be  thoroughly  scraped  and  disinfected.  Dressings  should  be 
antiseptic  in  character,  as  a  rule,  and  .should  exert  some  pressure  so  as  to 
cause  collapse  of  the  walls  of  the  cavity. 

Treat.ment. — Since  abscess  is  the  result  of  mycotic  inflammation,  the 
local  and  constitutional  means  previously  described,  as  appropriate  for 
the  cure  of  inflammation  by  resolution,  should  be  adopted  when  suppura- 
tion is  threatened.  A  blister  is  often  very  serviceable,  and  seems  to  dissi- 
pate the  suppurative  inflammation.  If  it  is  found  that  resolution  is  im- 
possible, rapid  maturation  and  evacuation  of  the  abscess  are  to  be  obtained, 
and  restoration  of  the  parts  to  a  normal  condition  promoted.  Hot  and 
moist  applications,  such  as  poultices,  soften  tissue  and  encourage  rapid 
migration  of  leucocytes  ;  hence,  they  are,  perhaps,  proper  when  resolution 
and  absorption  seem  hopeless.  Poultices  are  very  little  used  since  the 
advent  of  the  antiseptic  era,  and  more  early  operative  interference  than 
formerly  is  usual.  To  relieve  the  pain  and  tension,  and  prevent  disfigur- 
ing scars  and  destruction  of  tissue,  early  evacuation,  by  means  of  a  free 
incision  made  with  a  sharp  knife,  is  imperatively  demanded  in  all  cases  of 
acute  abscess.  Incision  made  before  pus  has  actually  formed  will  often 
cut  short  the  suppurative  process,  and,  if  made  sufHciently  free  to  relieve 
tension,  always  lessens  the  pain.  If  there  is  danger  of  wounding  large 
vessels  the  abscess  may  be  opened  on  a  grooved  director,  or  it  may  be 
torn  open  with  a  blunt  instrument  after  incision  of  the  skin.  Sometimes 
this  last  procedure  is  well  done  by  inserting  the  end  of  a  ])air  of  closed 
forceps  and  forcibly  opening  the  ends  of  the  blades.  In  all  cases  where 
the  cavity  is  large  the  orifice  should  be  kept  open  by  a  tent  made  of  a 
piece  of  antiseptic  gauze,  or  by  a  drainage  tube  ;  and  permanent  pressure 
should  be  ajjplied  by  means  of  a  bandage,  in  order  to  hasten  contraction 
and  granulation  of  the  sac  of  the  abscess.  Counter-openings  may  be 
necessary  when  the  pus  infiltrates  the  connective  tissue  or  burrows  or 
gravitates  into  pouches  which  jirevent  its  ready  escape. 

In  tubercular  abscess  the  treatment  is  the  same.  The  evacuation  of 
many  fluidounces  of  ])uriform  liquid  may,  by  exposing  the  wall  of  the 
abscess  to  the  air  with  its  septic  influences  and  by  the  sudden  relief  of  pres- 
sure to  which  the  surrounding  capillaries  were  accustomed,  lead  to  rigors, 
exhaustive  fever,  and  grave  constitutional  symptoms.  Hence,  as  the 
fluid  is  sometimes,  though  very  rarely,  absorbed,  and  chronic  abscesses 
may  remain  without  pointing  for  indefinite  periods,  it  was  formerly  the 
custom  with  many  to  abstain  from  operative  interference.  This  is  inju- 
dicious, for  withdrawal  of  the  so-called  pus  by  the  aspirator,  and  the 
application  of  firm  pi'essure,  or  incision  and  disinfection  under  the  strictest 
antiseptic  precautions,  are  now  believed  to  be  the  best  surgery. 

Hyper-distention  of  large  abscess  cavities  with  antiseptic  solutions 
forced  in  by  means  of  a  syringe  tightly  fitting  a  small  opening,  is  often  a 
good  procedure  to  be  adopted  as  soon  as  most  of  the  contents  have  been 
allowed  to  escape.     Thus  air  is  excluded,  the  customary  pressure  main- 


ULCERATION.  55 

tained,  and  constitutional  symptoms  lessened.  These  various  antiseptic 
measures  are  useful  in  acute  abscesses,  but  are  even  more  essential  in 
large  chronic  abscesses.  Supporting  remedies  and  anodynes  are  important 
in  all  cases  of  severe  or  prolonged  suppuration. 

The  local  treatment  of  all  abscesses,  then,  whether  acute  or  chronic, 
should  be  early  and  free  incision  with  strict  antiseptic  precautions.  The 
best  watery  solutions  to  use  in  washing  out  small  abscess  cavities  are 
corrosive  sublimate  (1  :  1000  to  1  :  5000)  and  betanaphthol  (1  :  2500). 
As  there  is  some  risk  of  poisoning  if  large  quantities  of  the  sublimate 
solutions  remain  in  large  and  irregular  cavities,  that  drug  must  be  used 
with  caution.  Betanaphthol  is  not  poisonous,  but  is  not  so  active  a 
germicide.  Solution  of  iodoform  in  ether  (1:50  to  1:500)  is  a  good 
material  for  injecting  the  cavities  of  tubercular  abscesses.  In  all  cases 
the  solution,  of  whatever  character,  is  subsequently  allowed  to  flow  from, 
or  is  pressed  out  of,  the  abscess  cavity. 

Sinus  and  Fistula. 

When  an  abscess  has  been  evacuated  it  may  not  contract  and  heal 
completely,  but,  especially  when  the  muscles  prevent  perfect  rest,  may 
leave  a  long,  narrow,  and  sinuous  canal  through  the  tissues.  This  is  lined 
by  a  membrane  having  somewhat  the  character  of  mucous  membrane, 
from  which  unhealthy  pus  is  discharged.  If  the  canal  has  only  one 
orifice  it  is  called  a  sinus  ;  if  more  than  one,  a  fistula  or  fistule.  The 
term  fistula  in  surgery  is  sometimes  limited  to  such  a  canal  communicat- 
ing with  one  of  the  hollow  organs,  as  the  bladder,  rectum,  or  lachrymal 
sac.  The  orifice  of  a  fistula  or  sinus  is  usually  surrounded  by  exuberant 
granulations  projecting  as  a  papilla.  Sinuses  and  fistules  are  cured  by 
destroying  the  adventitious  lining  membrane  and  setting  up  acute  inflam- 
mation, in  order  to  cause  healthy  granulations  to  take  place  from  the 
bottom.  This  may  be  done  by  irritating  injections,  the  actual  cautery, 
curetting,  or  by  laying  the  track  open  with  the  knife  or  elastic  ligature 
which  thus  controls  all  muscular  contraction ;  and  in  many  cases  still 
better  by  dissecting  the  whole  canal  out  and  approximating  the  healthy 
wound  so  made  with  sutures.  Any  source  of  irritation,  such  as  diseased 
bone  or  foreign  material,  must  be  removed  at  the  same  time. 

The  term  fistule  is  also  applied  to  a  communication  between  two 
hollow  viscera,  due  to  injury  or  sloughing.  Such  abnormal  openings  are 
cured  by  plastic  operations. 

Ulceration. 

When  inflammation  does  not  terminate  by  resolution  in  a  return  to 
health,  death  of  the  part  by  either  ulceration  or  gangrene  must  take 
place.  Ulceration  is  death  in  small  particles  or  molecules ;  gangrene  is 
death  in  masses  large  enough  to  be  seen.  Similar  processes  in  osseous 
tissue  are  called  caries  and  necrosis,  and  will  be  described  under  diseases 
of  bone.  The  causes  of  ulceration  are  the  same  as  the  causes  of  inflam- 
mation, to  which  ulceration  always  owes  its  existence.  It  may  occur 
superficially,  as  in  the  skin  and  cornea,  or  deeply,  as  in  the  substance  of 
organs,  for  abscesses  and  sinuses  are  practically  but  the  results  of  ulcera- 
tion. The  ulcerative  process  is  more  common  in  skin,  mucous  mem- 
branes, cartilages,  lymphatic  glands,  lungs,  and  bone  (called  caries),  than 


56  SUPPURATION. 

in  fibrous,  serous,  or  muscular  tissue.  Ulceration  consists  in  softening 
and  disintegration  of  structure,  followed  by  the  removal  of  the  debris  by 
absorption  and  ejection.  When  removal  of  tissue  is  effected  by  absorp- 
tion alone,  as  is  seen  in  erosion  of  tissue  from  aneurismal  pressure,  the 
term  interstitial  absorption  is  applicable,  since  ulceration  causes  removal 
chieHy  by  discharges. 

Ulceration  and  suppuration  are  closely  allied,  since  some  of  the  pus 
owes  its  existence  to  the  destruction  and  disintegration  of  tissue.  Sloughs 
and  foreign  bodies  in  the  tissues  arc  usually  thrown  off  by  ulceration  and 
suppuration  occurring  around  them. 

Ulceration,  then,  is  the  molecular  death  of  soft  tissues,  and  produces 
on  a  free  surface  the  anatomical  lesion  called  an  ulcer  or  open  sore. 

Ulcers. 

Definition. — An  ulcer  is  a  breach  of  continuity  of  surface,  covered  by 
granulations  and  usually  accompanied  by  a  di.-^charge  of  pus.  The  nature 
of  the  granulations  and  of  the  pus  determines  the  character  of  the  ulcer. 
The  solution  of  continuity  may  be  due  to  the  process  of  ulceration,  to 
gangrene,  or  to  a  wound  ;  for  in  gangrene  the  slough  is  separated  by 
ulceration,  and  wounds  that  do  not  heal  by  first  intention  become  ulcers 
as  soon  as  granulation  is  instituted.  A  solution  of  continuity  called  an 
ulcer  is  usually  deeper  than  the  epithelium  ;  if  not,  the  terms  abrasion, 
desquamation,  or  excoriation  are  commonly  applied.  Among  exceptions 
to  this  rule  may  be  mentioned  superficial  ulcers  of  the  cornea. 

Surgeons  are  called  upon  to  treat  ulcers  of  the  skin  and  mucous  mem- 
brane, and  to  these  alone  are  the  following  paragraphs  meant  to  apply. 

Varieties. — All  ulcers  are  direct  consequences  of  the  inflammatory 
process,  which  is  due  to  either  constitutional  or  local  causes.  The  causa- 
tion is  an  important  factor  in  the  treatment  of  ulcers,  but  does  not  require 
any  change  in  the  classification  of  them. 

"Ulcers  are  healthy  or  unhealthy.  The  healthy  ulcer  is  typically  illus- 
trated by  the  sore  produced  when  granulation  has  begun  in  a  wound 
made  by  cutting  out  a  portion  of  tissue.  The  edges  are  regular  and 
smooth,  and  slope  gradually  toward  the  granulations,  which  are  red.  pain- 
less, do  not  bleed  under  gentle  pressure,  secrete  a  serous  non-purulent 
fluid,  and  never  protrude  above  the  surface  of  the  skin.  The  granula- 
tions at  the  circumference  are  being  covered  by  or  converted  into  a  bluish- 
white  cicatricial  pellicle  of  epithelium,  while  the  skin  surrounding  the 
ulcer  is  purplish  and  somewhat  hardened  by  inflammatory  infiltration. 
All  ulcers  must  be  brought  to  this  condition  before  cicatrization  can 
occur,  and  so  long  as  the  ulcer  continues  healthy,  healing  goes  on  spon- 
taneou.sly  and  steadily  if  the  surface  be  only  protected  from  injurious 
contact.  Protection  is  best  eflected  by  applying  a  piece  of  aseptic  rubber 
tissue  or  oiled  silk  covered  with  an  aseptic  or  antiseptic  gauze  dressing. 
Some  surgeons  prefer  antiseptic  ointments,  such  as  carbolized  oxide  of 
zinc  ointment,  boric  acid  ointment,  and  ointment  of  petroleum ;  or 
lotions  or  powders  containing  some  germicidal  agent. 

Unhealthy  ulcers  are  those  accomjianied  by  seme  condition  which  pre- 
vents their  exhibiting  the  characteristics  above  mentioned.  If  undue 
inflammation  be  present,  as  shown  by  great  heat  and  pain,  cedematous 
surroundings,  engorged  granulations,  and  discharge  of  pus  mixed  with 
blood,  it  is  an  inflamed  ulcer.     If  this  process  be  violent  and  rapid,  de- 


ULCERS. 


57 


Fig.  2. 


struction  of  tissue  and  extension  of  ulceration  occur,  a  pellaceous  mass 
is  seen  covering  unhealthy-looking  granulations,  and  the  edges  become 
irregular  and  sharp-cut.  This  constitutes  a  "sloughing"  ulcer,  which  is 
a  rather  contradictory  term.  The  devitalized  skin  or  muscle  is  often 
found  in  the  discharge  from  such  an  ulcer,  as  shreds  and  tags  of  tissue. 

When  the  granulations  are  exuberant  and  project  like  excrescences  be- 
yond the  level  of  the  skin,  the  ulcer  is  called  a  fungous  ulcer.  The 
callous  or  indolent  ulcer  is  deeply  excavated,  has  indurated  whitish  and 
undermined  or  inverted  borders,  is  surrounded  by  thickened  and  con- 
gested skin  of  a  bluish  color,  shows  imperfectly-formed  pale  granulations 
covered  with  a  foul-smelling  thin  pus,  and  is  usually  insensible  to  painful 
contact.  Such  ulcers  are  of  long  duration,  and  may  well  be  termed 
chronic.  Ulcers  may  be  complicated  or  may  depend  upon  the  existence 
of  varicose  veins,  impeded  circulation, 
diseased  bone,  or  may  be  the  seat  of 
hemorrhage  or  of  malignant  processes. 
Other  circumstances  may  contribute 
to  the  production  of  complicated  or 
unhealthy  ulcers,  but  it  is  not  neces- 
sary to  give  a  distinctive  name  to  each 
one. 

Ulcers,  otherwise  healthy,  are  often 
the  seat  of  a  purulent  discharge,  be- 
cause of  pyogenic  germs  having  been 
allowed  to  come  into  contact  with  the 
ulcers'  surfaces.  Such  a  suj)purating 
ulcer  is  usually  denominated  a  healthy 
ulcer,  though  the  term  is  not  strictly 
applicable. 

Treatment. — The  criterion  in  the 
treatment  of  all  ulcers  is  the  condition 
of  the  edges.  If  the  borders  are  pink- 
ish and  smooth,  and  gradually  slope 
down  to  florid  granulations,  or  perhaps  are  separated  from  them  by  a 
narrow  line  of  bluish-white  epithelial  cicatricial  tissue,  it  is  certain  that 
the  ulcer  is  in  a  healthy  state,  and  only  requires  protection  from  irritation. 
Hence,  it  may  be  dressed  with  any  bland  non-irritant  application.  Car- 
bolized  ointment  of  the  oxide  of  zinc  is,  in  my  opinion,oneof  the  best,  if  the 
ordinary  aseptic  protective  silk,  or  rubber,  and  gauze  dressing  is  not  used. 
Cicatrization  usually  takes  place  from  the  edges  toward  the  centre,  and 
therefore  in  large  ulcers,  even  when  healthy,  the  action  of  the  cutaneous 
cells  at  the  margins  may  be  insufficient  to  complete  the  process,  or  if  able 
to  do  so,  may  be  very  slow  in  causing  healing  of  the  entire  ulcerated  sur- 
face. Centres  of  cicatrization  may  be  established  upon  the  ulcer  at  any 
number  of  points  by  applying  aseptic  grafts  of  skin  (Fig.  3). 

Skin-grafting  is  best  performed  by  thrusting  the  point  of  an  aseptic 
ordinary  sewing-needle  under  the  epidermis  of  the  inner  surface  of  the 
arm  or  thigh,  previously  made  aseptic,  and,  after  putting  the  skin  on  the 
stretch  by  raising  the  needle,  cutting  out  a  minute  portion  of  the  true 
skin  with  a  sharp  scalpel  or  scissors.  The  graft  taken  in  this  almost 
painless  and  bloodless  manner  is  then  to  be  gently  pressed  upon  the 
healthy  granulations  with  its  epidermic  surface  upward  and  a  gauze  dress- 
ing applied.  Any  number  may  be  engrafted.  The  grafts  at  first  shed 
their  cuticle  and  become  almost  invisible,  but  in  a  few  days  bluish-white 


Method  of  cutting  skin-grafts  by 
means  of  needle  and  scalpel. 


58 


SUPPURATION, 


spots  of  cicatricial  tissue  are  seen  at  the  points  where  some  grafts  have 
taken  root.  These  islands  grow  eccentrically  by  epithelial  cell  prolifera- 
tion, and  stimulate  the  periphery  of  the  ulcer  to  similar  activity,  so  tiiat 
the  cicatrizing  process  is  greatly  expedited  by  the  new  points  of  cutifica- 
tion,  which  gradually  coalesce  with  one  another  and  with  the  marginal 
skin.  The  pi'ocess  is  not  attended  with  much  success  unless  the  ulcer  be 
healthy.  Long  and  thin  shavings  of  skin  cut  from  the  patient  by  means 
of  a  sharp  razor  may  be  used  in  a  similar  way.  This  method  causes 
much  more  rapid  healing,  but  the  pain  is  rather  severe  when  the  shavings 
are  cut.  Skin  may  be  taken  from  a  living  frog's  abdomen  and  laid  upon 
the  ulcer.  Plastic  operations  may  be  performed  to  hasten  the  healing  of 
intractable  ulcers  by  the  transfer  of  healthy  integument  to  their  surfaces. 


Fio.  -.'>. 


Skin-grafting  in  traumatic  ulcer  of  the  scalp.    (Lkvis.) 

The  treatment  of  all  unhealthy  ulcers  must  be  directed  to  transforming 
them  into  healthy  ulcers,  and  is  both  constitutional  and  local.  If  they 
depend  upon  syphilis  specific  remedies,  such  as  mercury,  iodoform,  and  the 
iodides,  must  be  given  internally ;  if  the  tuberculous  diathesis  exist, 
iodine  and  its  derivatives,  cod-liver  oil  and  tonics,  are  required.  In  all 
cases  digestive  and  other  constitutional  vices  must  be  investigated  and 
treated.  Any  local  exciting  cause,  such  as  bone  disease  and  varicose 
veins,  must  be  removed,  or  at  least  palliated,  after  which  local  treatment 
is  to  be  regulated  by  the  condition  of  the  ulcer.  An  ulcer  accompanied 
by  acute  inflammation  mu.st  be  managed  on  the  principles  already  laid 
down  in  the  treatment  of  acute  inflammation.  Antiphlogistic  internal 
remedies  are  demanded,  while  elevation  and  rest  of  the  part,  scarification, 


MORTIFICATION,    OR    GAJSTGRENE.  59 

lead  water  and  laudanum,  warm  water  dressings,  or  weak  astringent  solu- 
tions are  used  locally.  When  the  inflammation  is  severe  enough  to  cause 
sloughing  ulceration,  supportive  treatment  and  poultices  to  hasten  separa- 
tion of  the  sloughs,  or  other  mild  applications  are  demanded.  The  local 
irritability  and  pain  which  characterize  manv  ulcers  are  often  greatly  les- 
sened by  the  application  of  solid  nitrate  of  silver,  or  strong  solutions  of 
the  same  (gr.  xx  to  fgj  of  water).  Subnitrate  of  bismuth  is  an  excellent 
local  remedy.  A  moist  antiseptic  gauze  dressing,  covered  with  oiled  silk 
or  rubber  tissue  to  prevent  evaporation,  is  far  better  than  the  old-fashioned 
poultice.     It  is,  in  fact,  an  antiseptic  poultice. 

Fungous  ulceration  is  treated  by  caustics,  such  as  deliquesced  chromic 
acid,  or  by  the  surgeon  cutting  away  the  exuberant  growth  with  the 
knife,  or  scraping  it  away  with  a  sharp  spoon.  Ulcers  exhibiting  pale, 
cedematous,  semi-transparent  granulations  require  stimulating  applications 
of  nitrate  of  silver  and  sulphate  of  copper,  in  solution  or  undiluted. 

Callous  or  indolent  ulcers  are  the  most  rebellious  to  treatment.  The 
hard  elevated  edges  must  be  softened  and  depressed,  and  the  accompany- 
ing venous  congestion,  shown  by  the  livid  skin  surrounding  the  sore,  re- 
moved. My  own  plan  is  to  apply  pure  carbolic  acid,  nitric  acid,  or  some 
other  chemical  cauterant,  to  the  insensitive  edges  and  to  the  foul  and 
semi-devitalized  tissue  covering  the  depressed  and  unhealthy  granulations. 
Then  a  moist  antiseptic  dressing  is  applied  for  a  few  days  to  separate  the 
slough  thus  produced  and  to  soften  the  callous  borders.  Subsequently 
scarification  around  and  through  the  ulcer  relieves  the  engorged  venous 
capillaries.  The  pressure  of  strips  of  adhesive  plaster  properly  adjusted,  or 
of  an  elastic  bandage  smoothly  applied  from  the  distal  extremity  upward, 
prevents  a  repetition  of  the  congestion,  and  stimulates  absorption  of  deposits 
and  cicatrization  of  the  ulcer.  Instead  of  using  the  caustic,  I  frequently  get 
rid  of  the  callous  margins  by  paring  them  away,  and  then  treat  with  anti- 
septic dressings  and  pressure,  or  the  whole  ulcer  may  be  scraped  awav  with 
a  curette  and  treated  as  a  recent  wound.  Astringents  and  disinfecting 
lotions  may  be  used  beneath  the  elastic  bandage.  Chronic  ulcers  of 
small  size  may  be  frequently  cured  with  rapidity  by  dissecting  them  out, 
freeing  the  surrounding  skin  from  its  deeper  attachments,  and  uniting 
the  edges  of  the  wound  by  sutures. 

Peroxide  of  hydrogen  is  said  to  render  a  foul  ulcer  aseptic  by  oxidizing 
the  devitalized  and  putrefying  discharges. 

Tubercular  ulcers  do  well  when  treated  with  powdered  iodoform. 

As  soon  as  unhealthy  ulcers  approach  the  healthy  condition  cicatriza- 
tion begins,  and  may  be  hastened  by  skin-grafting.  In  order  to  maintain 
a  healthy  state  of  the  sore  and  prevent  oedematous  and  fungous  granula- 
tions, slightly  stimulant  lotions  of  chloral  (gr.  v  or  x  to  f.lj),  sulphate 
of  copper  (gr.  iij-v  to  f^j),  sulphate  of  zinc  (gr.  v  to  fgj),  or  nitrate 
of  mercury  or  subnitrate  of  bismuth  in  solution,  ointment,  or  powder 
should  be  employed.  When  in  a  few  days  or  weeks  the  ulcer  gets  accus- 
tomed to  the  effect  of  one  agent  and  becomes  "  inactive,"  the  dressing 
must  be  varied,  for  a  new  impression  will  be  beneficial.  Mucous  ulcers 
are  to  be  treated  like  cutaneous  sores. 

MoRTiFiCATioisr,  OR  Gangrene. 

Definition. — Mortification,  or  local  death,  is  the  complete  and  per- 
manent cessation  of  vital  functions  in  a  part,  and  differs  from  ulceration 
in  the  devitalized  portion  being  more  extensive.     Ulceration  is  molecular 


60  SUPPURATION. 

death,  while  mortification  is  death  of  appreciable  areas  of  tissue,  that  is, 
of  tissue  in  mass.  The  two  processes  are,  however,  allied,  and  may 
co-exist,  as  in  hospital  gangrene  or  sloughing  phagediena,  where  ulceration 
is  too  rapid  for  disintegration  to  take  place.  The  dead  tissue  is  called  a 
slough  or  eschar.  Necrosis  is  often  used  by  pathologists  to  signify  death 
of  animal  tissues  in  mass  without  reference  to  the  character  of  the 
structures,  but  in  surgery,  necrosis  is  usually  applied  to  bone  and  carti- 
lage; and  mortification,  gangrene  or  sphacelation  to  soft  tissues. 

Causf.s. — jNLortification  is  due  to  defective  nutritive  supply  and  to 
destruction  of  cellular  activity.  The  former  condition  may  be  caused  by 
obstruction  in  the  arteries,  as  from  ligation,  rupture,  embolism,  plugging 
by  great  numbers  of  bacteria,  or  diseased  arterial  walls ;  obstruction  in 
the  veins,  as  from  tight  bandaging ;  obstruction  in  the  capillaries,  as  from 
pressure  of  tumors,  or  inflammatory  deposits ;  cardiac  weakness,  which  is 
merely  an  accessory  cause,  decreasing  the  activity  of  the  circulation  ;  in- 
flammation, by  its  intensity  inducing  permanent  arrest  of  circulation, 
or  by  its  specific  mycotic  cause  having  a  special  tendency  to  cau.se  destruc- 
tion or  devitalization  of  tissue. 

The  causes  which  induce  mortification  by  destroying  the  vitality  and 
activity  of  the  cellular  elements  are:  injuries,  which  disorganize  tissue; 
chemical  agents,  such  as  acids  and  alkalies;  the  ptomaines  of  putrefactive 
or  other  bacteria  acting  as  irritants  ;  and  excessive  heat  or  cold.  Morti- 
fication is  often  due  to  a  combination  of  several  of  the  causative  influences. 
Defective  iimervation  has  been  considered  a  cause  of  mortification,  but  it 
is  probable  that  it  acts  only  indirectly  by  diminishing  circulatory  activity, 
or  by  rendering  parts  less  cognizant  of  the  contact  of  irritating  agents. 
The  power  of  the  cells  to  resist  gangrenous  causes  varies  in  individuals 
and  in  tissues. 

Varieties. — ]\[ortification  may  be  moist  or  dry,  according  to  the  causa- 
tion and  circumstances  attending  the  process.  If  the  parts  contain  much 
fluid,  as  is  the  case  when  the  mortification  is  associated  with  venous 
obstruction  and  when  evaporation  is  prevented  by  the  integrity  of  the 
cuticle,  the  process  resembles  the  ordinary  putrefaction  of  animal  sub- 
stances as  seen  in  dead  bodies.  This  is  called  moist  gangrene.  The  local 
symptoms  are  due  to  the  fact  that  ordinai-y  putrefaction  is  occurring 
because  putrefactive  fungi  have  gained  access  to  the  dead  tissue  through 
the  skin.  It  the  gangrene  is  due  to  slowly  progressive  arterial  obstruc- 
tion while  venous  and  lymphatic  absorption  is  not  decreased,  or  if  rapid 
evaporation  occurs  on  account  of  the  destruction  of  the  cuticle,  the  parts 
become  shrivelled  and  dry,  and  dry  gangrene  is  said  to  exist.  Acute  gan- 
grene is  usually  moist,  because  it  dies  quickly  when  full  of  blood,  while 
chronic  mortification  is  generally  dry.  Soft  and  vascular  tissues  mortify 
much  more  rapidly  than  dense,  non-vascular  structures,  such  as  tendons 
and  cartilages. 

The  infarctions  found  after  embolism  of  renal  and  other  arteries,  the 
caseous  change  that  occurs  in  scrofulous  products,  and  similar  pathological 
conditions,  are  examples  of  what  has  been  called  coagulation-necrosis, 
which  is  a  change  of  protoplasm  into  a  material  resembling  the  fibrin  of 
the  blood.  With  this  form  of  mortification  surgical  pathology  has  little 
concern. 

Symptoms. — The  constitutional  symptoms  of  gangrene  are  almost  in- 
variably asthenic,  probably  because  the  blood  becomes  deteriorated  by 
the  admission  of  septic  products  derived  from  the  sloughing  tissues. 


MORTIFICATION,    OR    GANGRENE: 


61 


The  feeble  circulation  and  general  nervous  depression  accompanying  a 
very  limited  ai'ea  of  mortification  are  often  remarkable. 

The  local  symptoms  of  moist  and  dry  gangrene  differ  and  must  be  dis- 
cussed separately.  In  the  moist  variety  the  parts  become  green,  bluish, 
or  black,  lose  their  normal  sensibility  and  temperature,  and  become 
softened  and  covered  with  blebs  containing  reddish-brown  fluid.  The 
epidermis  is  easily  rubbed  off,  leaving  a  dark,  smooth  surface.  Pi-essure 
causes  a  crackling  sound,  due  to  the  presence  in  the  tissue  of  the  gases 
generated  by  putrefactive  decomposition.  The  gases,  which  are  prin- 
cipally sulphuretted  hydrogen,  ammonia,  and  carbonic  acid,  cause  great 
local  emphysema  and  pufiiness  of  the  parts,  and  with  the  other  products, 
such  as  butyric  acid,  give  the  characteristic  odjr  of  putrefaction.  The 
red  streaks  along  the  course  of  the  vessels  in  the  iucipiency  of  gangrene, 
and  the  deep  color  of  the  parts  during  its  existence  are  due  to  the 
transuded  coloring  matter  liberated  by  the  destruction  of  the  blood 
corpuscles. 

Fig.  4. 


£^ 


Senile  gangrene  of  arm. 


In  dry  gangrene  the  appearance  of  a  small  brown  or  black  spot,  espe- 
cially upon  the  toes,  where  the  affection  is  most  frequently  seen,  is  often 
the  first  sign  of  disease  ;  though  at  times  cramps,  and  stinging  pain,  and 
feeble  local  circulation  are  premonitory  symptoms.  The  discolored  point, 
instead  of  being  brown  may  be  a  mottled  white,  and  sometimes  a  vesicle 
forms  at  the  beginning  of  the  disease.  The  darkened  area  becomes 
blacker  and  slowly  extends  with  very  few  accompanying  inflammatory 
symptoms.  The  dead  tissue  is  dry,  without  offensive  odor,  and  gradually 
becomes  shrivelled  and  hard.  The  loss  of  sensibility  and  the  lowered 
temperature  of  the  dead  tissue  present  in  moist  gangrene,  of  course, 
exist  here.  This  form  of  mortification  is  frequently  called  senile  gan- 
grene, but  improperly  so,  since  it  may  occur  from  chronic  ergotism  with- 
out reference  to  the  patient's  age,  and  because  moist  gangrene  may  occur 
in  the  aged  in  similar  regions  of  the  body. 

In  all  forms  of  mortification,  if  the  patient  survive  long  enough,  the 
dead  tissues  are  separated  by  the  process  of  ulceration  from  those  whose 
vitality  resists  the  destructive  influence.  The  living  structures  become 
reddened  at  the  line  of  junction  with  the  slough,  and  thus  constitute  the 
line  of  demarcation  which  indicates  the  extent  to  which  the  devitalizing 
process  has  been  able  to  exert  its  influence.  Sometimes  a  row  of  vesicles 
forms  along  this  margin.  The  line  of  demarcation  soon  becomes  con- 
verted into  a  groove  which  is  lined  by  granulations  secreting  pus.  This 
is  practically  a  linear  ulcer,  and  is  called  the  line  of  separation,  because 
the  ulcerative  and  granulating  processes  gradually  push  off  the  dead 
tissues  by  a  sj)ecies  of  natural  amputation  and  leave  an  ulcer  to  heal 
by  cicatrization.     ;Hemorrhage  is  prevented  by  coagulation  within  the 


62  SUPPURATION. 

arteries  and  fibrinous  dcjxisition  duv  to  the  infianimatory  action.  The 
inflammation  acconipanying  niortitiiation  often  gives  rise  to  great  pain, 
which,  of  course,  is  located  in  the  living  or  partially  devitalized  struc- 
tures. This  increases  the  general  depression  due  to  septic  influences  of  the 
gangrenous  parts.  When  mortification  occurs  in  deep  structures,  the 
slough  is  thrown  off  through  fistulous  orifices,  as  occurs  in  carbuncle,  and 
as  is  attempted  by  nature,  though  often  unsuccrssfully,  in  necrosis  of  bone  ; 
or,  it  may  become  encapsulated  and  thus  be  separated  from  the  surround- 
ing living  structures.  The  latter  mode  of  separation  is  seen  in  infarc- 
tions of  the  internal  organs. 

Treatment. — The  general  treatment  of  all  forms  of  gangrene,  to  be 
judicious,  should  be  directed  to  fulfil  two  indications  :  first,  to  remove 
the  cause  and  thus  arrest  the  progress  of  the  gangrenous  action  ;  and, 
secondly,  to  sustain  the  j)atient  until  separation  of  sloughs  has  occurred. 
Unfortunately,  the  constitutional  cause  is  often  difficult  of  removal,  but 
an  effort  should  be  made  to  bring  the  system  into  that  condition  which 
will  render  the  causative  factors  as  inoperative  as  possible,  and  limit  the 
mortification.  If  the  peripheral  circulation  is  poor  because  of  a  feeble 
heart  and  degenerated  arteries,  remedies  such  as  (juinia,  iron,  opium, 
digitalis,  strychnia,  alcohol,  etc.,  should  be  administered  and  the  patient 
protected  from  cold  and  other  depressing  influences.  When  there  is  a 
tendency  to  a  sthenic  type  it  is  possible  that  slightly  depressing  agents 
may  be  advantageous,  but  these  are  seldom  needed  and  should  be  used 
with  great  caution,  since  the  advent  of  gangrene  is  soon  followed  by 
nervous  and  circulatory  prostration. 

During  the  stage  of  separation  of  sloughs  the  flagging  powers  of  the 
patient  must  always  be  supported  by  active  medication  with  tonics,  stimu- 
lants, and  concentrated  nutritious  diet.  Depressing  antiphlogistic  reme- 
dies are  never  justifiable  ;  and  if  nervous  irritability  and  pain  exist  opium 
in  full  doses  is  to  be  employed.  Cleanliness,  disinfection,  and  ventilation 
are  necessary  hygienic  measures.  The  local  treatment  of  mortification  is 
very  important. 

If  gangrene  is  threatened  on  account  of  the  tension  produced  by  rapid 
and  intense  inflammatory  swelling,  it  may  often  be  averted  by  free  inci- 
sions several  inches  in  length  through  the  skin,  subcutaneous  and  fascial 
structures.  This  treatment  relieves  local  tension  by  permitting  gaping 
of  the  wound  and  affording  a  free  escape  of  blood  and  inflammatory 
products.  Much  tissue  destruction  is  thus  avoided  by  removing  the 
obstruction  to  capillary  circulation.  Parts  prone  to  slough  from  deficient 
circulation  should  be  kept  normally  warm.  When  gangrene  has  occurred 
disinfectant  lotions  of  carbolic  acid  of  an  uuirritating  strength  (1  :  20 
or  30),  corrosive  sublimate  (1 :  1000  or  3000),  chlorinated  soda,  chloride 
of  zinc  (1 :  50  or  100),  or  desiccating  powders  of  a  disinfectant  nature, 
.should  be  used  to  destroy  the  fetor  of  the  parts.  These  should  be  com- 
bined with  anti.septic  gauze  dressings,  perhaps  made  moist  and  covered 
with  oiled  silk  or  waxed  paper,  in  order  to  encourage  and  hasten  separa- 
tion of  the  devitalized  tissues.  The  sloughs  may  be  removed  in  pieces 
with  the  forceps  and  scissors  after  the  line  of  separation  has  divided  the 
vascular  attachments.  Tendons  and  fibrous  tissues,  as  they  contain  no 
vessels  of  importance,  may  be  carefully  cut,  for  in  this  manner  the  de- 
composing masses  can  be  removed  somewhat  earlier.  No  special  dressing 
is  to  be  applied  to  the  line  of  separation.  The  ulcer  left  after  the  slough 
has  been  detached  is  to  be  dressed  with  mild  applications,  such  as  carbol- 
ized  oxide  of  zinc  ointment,  ointment  of  petroleum  and  boric  acid,  or 


HOSPITAL    GANGRENE.  63 

antiseptic  gauze,  as  in  ordinary  ulcers.    Cicatrization  is  to  be  encour- 
aged. 

When  mortification  depends  on  a  known  local  cause,  such  as  crushing  of 
the  parts,  or  ligation  or  rupture  of  the  main  artery,  amputation  should  be 
performed,  except  in  cases  due  to  frost-bite  or  burns  above  the  location 
of  injury,  without  waiting  for  the  line  of  demarcation.  If  the  gangrene 
is  due  to  constitutional  causes,  such  as  deficient  circulation,  or  ergotism,  or 
to  the  presence  of  an  embolus  Avhose  location  is  unknown,  the  surgeon 
must  wait  until  the  line  of  separation  is  well  marked  before  attempting 
operative  interference,  since  the  extent  of  the  gangrenous  influence  can- 
not otherwise  be  estimated.  In  traumatic  cases  where  gangrene  is  inevit- 
able, amputation  should  be  promptly  performed. 

Hospital  Gangrene. 

Hospital  gangrene,  or  sloughing  phagedsena,  is  a  peculiar  form  of 
rapidly  spreading  mortification  or  gangrenous  ulceration,  which  attacks 
wounds  or  injuries  where  the  epidermis  is  broken,  when  patients  are  sub- 
jected to  the  foul  air  of  overcrowded  hospitals  and  the  wounds  infected  by 
certain  bacteria.  It  is  exceedingly  contagious  and  infectious,  and  may  at 
times  begin  as  a  vesicle  if  the  parts  are  not  much  denuded  of  cuticle. 
The  ulcer  resulting  is  painful,  covered  with  grayish  sloughs,  and  dis- 
charges excessively  fetid,  brownish  fluid.  The  edges  of  the  ulcer,  as  a 
rule,  are  sharply  cut.  The  connective  tissue  is  rapidly  invaded,  and  pro- 
fuse hemorrhage  may  occur.  The  constitutional  symptoms,  which  are 
secondary,  are  markedly  asthenic.  The  disease  is  of  local  origin,  due  to 
wound  infection,  and  must  be  treated  as  such.  The  patient  should  at 
once  be  removed  to  uninfected  quarters,  such  as  a  tent,  or  pavilion  hos- 
pital, and  all  the  instruments,  dressings,  and  sponges  be  sterilized  or 
destroyed.  The  sloughs  should  be  lifted  off,  if  possible,  and  the  entire 
wound  saturated  with  undiluted  nitric  acid,  bromine,  or  other  powerful 
cauterant  to  destroy  the  septic  germs.  The  caustic  must  corrode  the 
healthy  tissue  in  order  to  get  beyond  the  gangrenous  influence.  The 
actual  cautery  is  probably  valuable  in  such  cases.  Tonics,  stimulants, 
and  other  supportive  treatment  generally  combined  with  opium  are 
required  internally. 

Fortunately,  the  aseptic  and  antiseptic  methods  of  modern  surgery 
have  made  hospital  gangrene  practically  unknown. 


CHAPTER    III. 

ERYSIPELAS,   SAPR.EMIA,   SEPTICEMIA,   ETC. 

ERYSIPELAS. 

Description. — Erysipelas  is  an  acute  febrile  affection,  usually  of"  a  low- 
type,  due  to  sojue  mycotic  blood  contamination,  aud  accompanied  by  a 
rapidly  spreading  inflammation,  which  has  no  tendency  to  limit  itself  by 
the  exudation  of  plastic  matter.  It  is  most  fre([uently  met  in  the  tegu- 
mentary  structures,  but  may  attack  mucous  aud  serous  tissues  as  well.  As 
seen  by  the  surgeon  it  generally  occurs  as  a  complication  of  wounds,  but 
may  arise  idiopathically.  Simple  or  cutaneous  erysipelas  involves  the 
skin  alone,  while  in  the  phlegmonous  or  cellulo-cutaneous  variety  the  sub- 
cutaneous tissue  is  also  inflamed.  If  the  inflammatory  process  spreads 
through  the  cellular  or  connective  tissue  without  invading  the  skin,  it  is 
called  diffuse  cellulitis  or  cellular  erysipelas. 

It  is  an  infectious  and  contagious  disease,  and  is  particularly  liable  to 
attack  those  debilitated  by  bad  hygienic  surroundings  or  depressed  by 
intemperance  or  by  renal  and  hepatic  affections.  The  septic  germs  con- 
tained in  putrefying  dead  bodies  have  some  occult  influence  in  the  induc- 
tion of  ervsipelas.  It  appears  to  be  allied  to  septiciiemia,  and  also  follows 
bites  of  venomous  reptiles,  etc.  It  is  uncertain  whether  it  is  due  to  a 
special  vegetable  parasite,  or  results  from  the  streptococcus,  which  causes 
diffuse  suppuration.  Many  believe  that  suppuration  occurring  in  the 
course  of  erysipelas  is  indicative  of  a  seccmdary  infection  with  pus  fungi. 

Symptoms. — The  constitutional  symptoms  may  be  of  a  sthenic  type, 
but  unless  the  disease  is  very  mild  and  short  in  its  course,  they  soon 
present  the  characteristics  of  asthenia.  Fevers,  rigors,  nausea,  vomiting, 
coated  tongue,  constipation,  and  perhaps  delirium,  are  the  early  symptoms, 
which  are  not  lessened  by  the  appearance  of  the  eruption,  aud  are  followed 
by  frequent  quick  pulse,  muttering  delirium,  dry  tongue,  sordes  and  often 
by  diarrhoea,  and  not  very  infrequently  by  death.  In  the  cutaneous  and 
cellulo-cutaneous  forms  the  burning  or  throbbing  pain,  the  scarlet,  or 
dusky -red,  shining  skin,  with  a  distinctly  elevated  margin,  the  oedema- 
tous  or  brawny  character  of  the  swollen  part,  the  tendency  to  spread, 
and  the  lymphatic  glandular  involvement,  make  the  diagnosis  sufficiently 
distinctive.  Vesicles  may  form  and  be  succeeded  by  a  brawny  desqua- 
mation. Sometimes  in  the  cellulo-cutaneous  variety  suppuration  or 
gangrene  of  the  connective  tissue  occui's  ;  then  the  skin  is  apt  to  become 
less  scarlet  in  color,  and  the  parts  have  on  palpation  an  oeJematous  or 
boggy  feel.  There  is  no  sign  of  pointing,  but  incision  discloses  a  diffuse 
form  of  abscess  in  the  areolar  tissue,  and  gives  escape  to  shreds  of  gan- 
grenous tissue  and  unhealthy,  foul-smelling  pus. 

When  erysipelas  attacks  a  wound  the  pus  from  it  becomes  lessened,  the 
granulations  degenerate,  the  union  breaks  down,  and  the  local  symptoms, 
mentioned  above  are  presented  about  the  wound.  Cellular  erysipelas, 
often  called  diffuse  cellulitis,  resembles  the  cellulo-cutaneous  variety,  but 
usually  arises  secondarily  to  a  wound,  and  presents  fewer  characteristics 
of  inflammation  of  the  skin.     Its  evident  relationship  to  erysipelas  is 


SAPR^MIA,    SEPTICEMIA,    AND    PYEMIA.  65 

admitted,  but  the  term  cellulitis  seems  preferable  to  cellular  erysipelas. 
This  variety  of  erysipelas  may  attack  the  areolar  tissue  in  the  pelvis  and 
other  internal  regions  if  they  be  opened  by  a  wound.  The  probability 
of  causing  puerperal  septie£eraia  by  inoculation  from  erysipelatous  cases 
must  always  be  borne  in  mind  by  the  obstetrician  or  surgeon. 

An  attack  of  erysipelas  lasts  from  one  to  two  weeks,  and  in  persons  of 
fair  health  previously,  is  usually  followed  by  recover}'.  The  subcutaneous 
forms  have  a  much  more  unfavorable  prognosis  than  the  cutaneous. 

Treatment. — Preventive  measures  consist  in  ventilation  and  steriliza- 
tion of  instruments  and  dressings.  At  first  a  purge  should  be  given  and 
light  diet  ordered,  but,  as  a  rule,  depressing  treatment  is  inapplicable, 
because  the  disease  soon  assumes  a  low  type.  Hence  ten  minims  of  tinc- 
ture of  iron  every  two  or  three  hours,  combined,  perhaps,  with  two  grains 
of  quinia  at  each  dose,  is  the  best  treatment.  Opiates  and  stimulants 
may  be  demanded.  Milk  and  beef  essence,  or  meat  juices,  are  the  best 
articles  of  diet.  A  mixture  of  one  part  of  laudanum,  one  part  of  lead- 
water,  and  two  parts  of  water,  a  combination  of  lime-water  and  sweet 
oil,  or  a  non-irritating  antiseptic  lotion  or  ointment,  should  be  applied 
locally.  If  suppuration  and  gangrene  threaten,  or  if  great  tension  is 
present,  numerous  incisions,  which  will  gape  widely,  should  be  made 
aseptically,  and  be  followed  by  antiseptic  gauze  dressings.  When  pus 
burrows,  as  in  the  subcutaneous  forms  of  the  disease,  the  cavities  should 
be  injected  with  carbolized  water  (1  :  40),  or  solution  of  corrosive  subli- 
mate (1  :  2000),  and  drainage-tubes  inserted  and  counter-openings  made. 


Sapr.emia,  Septict-mia  and  Pyaemia. 

Definition. — There  are  four  conditions  often  confused  which  ought  to 
be  distinguished ;  though  it  is  admitted  that  a  clinical  diagnosis  is  fre- 
quently impossible. 

They  are : 

1.  Aseptic  ivound-fever,  arising  in  connection  with  aseptic  wounds,  and 
due,  probably,  largely  to  poisoning  by  the  so-called  fibrin  ferment. 
This  is  given  off  during  the  disintegration  of  leucocytes  which  occurs  in 
inflammation  at  the  time  the  exudate  coagulates.  The  inflammatory  fever 
usually  seen  is,  however,  one  of  the  forms  of  septic  poisoning  mentioned 
below,  and  is  due  to  imperfect  asepsis.  If  the  wound  is  absolutely  aseptic 
the  wound-fever  is  always  inconsiderable. 

2.  Saprcemia,  putrid  poisoning,  or  septic  intoxication,  which  is  a  febrile 
condition,  due  to  the  chemical  products  or  ptomaines  developed  by  putre- 
faction of  animal  tissues,  either  in  the  wound  or  entirely  away  from  the 
body  of  the  patient.  This  poison  may  gain  access  to  the  blood  by  its  devel- 
opment and  retention  in  insufficiently  drained  putrescent  wounds  ;  or,  it 
may  be  obtained  experimentally  and  be  injected  hypodermatically.  The 
poison  is  the  result  of  mycotic  action,  of  course,  for  putrefaction  is  due 
to  fungi  of  putrefaction.  The  symptoms  of  saprgemia  occur  immediately 
after  inoculation,  but  it  requires  a  comparatively  large  dose  to  produce  a 
toxic  effect. 

3.  Septiccemia,  or  septic  infection,  a  fever  due  to  infection  by  putrefac- 
tive microorganisms  which  enter  the  blood  by  the  mucous  membranes  or 
by  a  wound,  usually  by  the  latter,  and  do  not  produce  symptoms  until 
they  have  had  time  to  multiply.  The  clinical  symptoms  are  similar  to 
those  of  saprgemia,  but  a  most  minute  dose  is  sufficient  to  lead  to  violent 


66  SAPR.EMIA,    SEPTICEMIA,    AND    PYAEMIA. 

syniptunis.     Tlu-  coiidition  formerly  called  hectic  fever  corresi  onds  with 
what  is  now  called  sa{)ra'inia  and  .^epticoemia. 

4.  Fi/cemia,  a  condition  in  which  the  general  febrile  disturbance,  similar 
to  septicemia,  is  due  to  j)yogenic  germs,  and  in  which  secondary  foci  of 
inflammation  or  su])puration,  called  metastatic  abscesses,  are  formed  in 
the  lungs,  liver,  and  other  organs.  These  abscesses  in  distant  organs  are 
due  to  the  trans})ortation  in  the  blood-stream  of  emboli  iniiected  with  pus- 
causing  bacteria.  Pyjen)ia  is  probably  simply  a  n)u]ti])le  suppurative 
inflammation.  The  old  theory  that  i)yiemia  is  a  condition  in  which  the 
blood  contains  pus  is  untenable,  though  the  derivation  of  the  word 
pysemia  still  suggests  it. 

The  relations  of  sapr?emia,  scptica?mia,  and  pyaemia  are  not  perfectly 
understood.  They  niay,  therefore,  be  considered  together,  at  least  until 
their  clinical  relations  and  pathology  are  further  investigated.  Some 
authors  believe  pya?mia  to  be  identical  with  what  I  have  called  septi- 
caemia, except  that  the  poisoning  is  more  intense. 

Pathology. — The  peculiar  poison,  which  by  introduction  into  the 
blood  causes  sapra?mic  conditions,  is  associated  with  putrid  decomposition 
of  albuminous  fluids,  and  is  connected  with  the  production  of  ptomaines 
by  the  bacteria  causing  the  putrefactive  process.  Septictemia  and  pyaemia 
are  due  to  infection  by  microcirganisms  themselves ;  the  former  by  the 
microorganisms  of  putrefaction,  the  latter  by  the  microorganisms  of  sup- 
puration. It  is  usually  necessary  that  there  exist  some  abnormal  state  of 
the  tissues,  such  as  inflammation,  before  the  presence  of  such  microbes 
can  induce  these  conditions.  The  occurrence  of  septicaemia  and  pytemia 
is  promoted  by  such  conditions  as  favor  the  contact  of  wound  surfaces 
with  ])articles  of  decomposing  animal  tissue,  or  of  dust  containing  pyo- 
genic bacteria,  such  as  necessarily  circulate  in  ill-ventilated  apartments 
containing  numerous  surgical  patients.  Septic  and  infective  substances 
thus  introduced  into  animal  fluids  encourage  therein  putrefactive  changes 
and  the  generation  of  infecting  organisms.  It  is  necessary,  however, 
in  order  to  infect  the  system,  that  the  poisonous  principle  be  absorbed. 
A  recent  wound,  or  one  covered  with  unhealthy  granulations,  allows 
rapid  absorption  of  the  poisonous  substances,  while  healthy  granulations 
seem  to  act  as  a  barrier  to  septic  infection.  The  blood  in  septicaemic  con- 
ditions is  less  coagulable  than  in  health,  and  the  red  corpuscles  show  a 
tendency  to  congregate  in  irregular  masses,  and  to  undergo  ante-mortem 
disintegration.  In  addition,  congestions  of  organs  and  stasis  of  the 
blood-current  are  frequently  observed.  The  autopsy  frequently  shows 
softening  and  degeneration  of  viscera,  ecchymosis  and  even  inflamma- 
tion of  the  serous  membranes,  and  changes  in  the  glands  and  mucous 
membrane  of  the  intestines. 

Pyaemia  may  be  provisionally  considered  as  septicaemia  with  the  addi- 
tion of  disseminated  spots  of  inflammation  and  suppuration.  These  con- 
sist of  metastatic  abscesses  in  lungs,  liver,  spleen,  and  other  viscera,  due 
to  embolism  and  bacterial  infection,  and  suppuration  in  joint  cavities  or 
inflammation  of  cellular  and  serous  tissues,  caused  either  by  embolism  or 
the  blood-change.  ]\[etastatic  abscesses  commence  as  small,  reddish,  and 
usually  pyramidal  sections  of  solidified  tissue,  w'hich  are  found  most  fre- 
quently near  the  periphery  of  the  lungs,  liver  and  spleen.  These  soon 
break  down  into  pus,  producing  abscesses,  which  are  always  small,  and 
which  are  surrounded  by  indurated  tissue.  These  multiple  or  metastatic 
abscesses  result  from  the  process  of  embolism  as  follows :  At  the  seat  of 
the  original  inflammation  coagulation  takes  place  in  the  vessels,  and  on 


SAPR^MIA,    SEPTIC^itlA,    AND    PYEMIA. 


67 


account  of  puriform  softening  of  these  clots  or  thrombi,  due  to  septic  in- 
fluences, small  particles  of  the  thrombi,  are  "u-ashed  into  the  circulation, 
carrying  along  with  them  pyogenic  bacteria.  These  emboli  lodge  in  the 
capillaries  of  the  lungs  or  other  viscera,  cause  impairment  of  circulation, 
and  by  their  mycotic  nature  give  rise  to  numncous  suppurative  points 
called  metastatic  or  embolic  abscesses. 


Fig.  5. 


Fig.  6. 


Diagram  of  thrombus  in  a  vein.  a.  cen- 
tral end  of  a  venous  thrombus  projecting 
into  a  large  trunk,  b.  small  branch.  The 
blood  flowing  from  small  branch  may 
readily  detach  a  part  of  the  thrombus. 
(Billroth.) 


Embolus  (E)  impacted  at  the  bifurcation 
of  a  branch  of  the  pulmonary  artery.  Sec- 
ondary thrombi  [t  and  t'),  behind  and  in 
front  of  embolus,  extending  to  the  first 
collateral  branches.    (Viechott.) 


Pysemia  is  probably  not  an  actual  disease,  but  simply  a  transference  of 
suppuration  by  means  of  emboli  and  their  accompanying  pus-causing 
germs.  It  is  a  complication,  or  variety,  then,  of  suppurative  inflamma- 
tion; due  perhaps  to  putrefactive  germs  having  caused  softening  of  the 
thrombi.  Hence  the  frequent  association  of  septic?emic  conditions  and 
pyaemia. 

Causes. — The  exciting  cause  of  septicaemia  is  the  peculiar  poison 
already  described  as  usually  generated  by  the  mycotic  decomposition  of 
albuminous  fluids.  The  poison,  under  the  name  of  sepsin,  is  believed 
to  have  been  isolated ;  but  our  knowledge  of  the  nature  of  the  agency 
inducing  septicsemic  conditions  is  very  limited.  Any  condition  which 
tends  to  produce  septic  material  in  the  patient's  body  may  be  called  a 
predisposing  cause.  The  most  frequent  of  all  is  the  existence  of  a  w^ouud, 
though  it  is  possible  that  septicaemia  may  result  from  septic  changes  in 
the  fluids  of  the  body,  due  to  agencies  introduced  by  absorption  through 
the  mucous  membranes.  Hemorrhage,  protracted  shock,  erysipelas,  osteo- 
myelitis, puerperal  lesions,  overcrowding  of  patients  afiected  with  suppu- 
rative diseases,  and  bad  hygienic  surroundings  are  important  predisposing 
causative  factors. 


68  SAPR^MIA,    SEPTICEMIA,    AND    1'YJ<:MIA. 

Symptoms. — The  first  symptom  of  septiciemia  or  of  ))yieinia  is  often 
a  sudden  rigor  preceded  or  accompanied  l)y  a  rise  in  temperature,  whicli 
is  followed  by  exhaustive  sweating  with  rapid  lowering  of  bodily  tem- 
perature. These  phenomena  resemble  those  of  nnilarial  fevers,  but  the 
hot  stage  between  the  rigor  and  the  sweating  is  less  marked.  The  tem- 
perature during  the  chill  may  rise  to  104°-107°,  and  during  the  sweating 
period  may  fall,  though  rarely,  to  normal  or  below.  The  rigors  and 
great  temperature  cluinges  are  repeated  at  more  or  less  irregular  inter- 
vals. The  i)ulse  is  increased  in  frequency,  but  diminished  in  force,  beat- 
ing 90-120  i)er  minute  ;  and  respiration  is  similarly  affected,  being  more 
frequent  and  less  deep.  The  breath  and  emanations  from  the  body  have 
a  sweetish  odor  which  is  of  some  diagnostic  value  in  septicsemic  states. 
The  tongue  is  usually  furred,  w^hile  nausea,  vomiting,  and  diarrh(ea  are 
frequently  present.  The  skin,  which  has  a  pale  or  yellowish  hue,  due  to 
pigment  from  disorganized  corpuscles,  may  present  sudaraina,  and  even 
an  ecchrmotic  or  a  pustular  eruption.  Albuminuria  is  not  infrequent 
and  delirium  is  common.  As  the  disease  progresses  the  symptoms  assume 
the  asthenic  or  typhoid  character  as  shown  by  rapid  emaciation,  great 
exhaustion,  twitching  of  the  tendons,  drowsiness,  low  muttering  delirium 
or  coma,  dry  and  brown  tongue,  sordes  upon  the  teeth,  colliquative 
diarrhcea  and  sweating.  The  wound  during  this  time  usually,  but  not 
always,  assumes  an  unhealthy  character  of  granulations  and  discharge. 
In  most  cases  the  discharge  of  pus  decreases,  and  it  may  entirely  disap- 
pear. About  the  sixth  or  tenth  day,  if  pyicraia  and  not  mere  septiciemia 
exist,  the  formation  of  metastatic  abscesses  and  the  occurrence  of  other 
inflammatory  foci  give  rise  to  jaundice,  cough,  pain  which  is  often  intense 
in  the  joints,  and  suppurative  or  inflammatory  signs  in  the  viscera  and 
elsewhere. 

The  lobular  pneumonia,  hepatitis,  pleuritis,  pericarditis  and  other  in- 
flammations that  at  times  occur,  give  rise  to  their  characteristic  symptoms. 
The  prognosis  is  always  unfavorable,  as  in  acute  cases  death  takes  place, 
as  a  rule,  in  from  one  to  two  weeks,  and  in  chronic  cases  in  from  one  to 
two  months.  Kecovery,  however,  does  at  times  occur  after  a  protracted 
convalescence.  It  is  often  impossible  to  discriminate  between  ctises  of 
septicaemia  and  pyaemia  until  theautopsy  proves  or  disproves  the  existence 
of  metastatic  abscesses.  The  symptoms  have,  therefore,  been  grouped 
together  as  representing  conditions  which  are  often  indistinguishable 
during  life. 

Diagnosis. — Septicaemia  or  pytemia  may  be  confounded  with  malarial 
or  typhoid  fever.  The  suddenness  and  intensity  of  the  rigor  and  of 
the  temperature  rise,  the  irregular  occurrence  of  these  phenomena,  the 
great  fall  in  temperature,  which  seldom  reaches  the  normal  before  the 
occurrence  of  another  rise,  the  profuse  sweating  which  follows  the  rigor 
without  the  intervention  of  a  marked  hot  stage,  and  the  association  of 
these  symptoms  in  many  instances  with  a  wound,  usually  serve  to  render 
a  differential  diagnosis  possible.  Quinine  will  usually  modify  malarial 
conditions  but  not  septic  ones.  Ordinary  inflammatory  fever  difl^ers  from 
septicaemia  because  it  usually  ceases  when  suppuration  begins.  Rheum- 
atism is  at  times  distinguished  with  difficulty  from  chronic  pyaemia,  but 
the  acute  forms  of  the  diseases  differ,  because  rheumatic  effusion  into  the 
joint  cavities  is  seldom  purulent  as  in  pytemic  synovitis.  Again,  the  sour 
odor  of  acute  rheumatism  is  replaced  by  the  sweetish  smell  often  noticed 
about  septicaemic  cases.     The  rapidity  of  emaciation  and  the  fatal  issue 


SAPR^]MIA,    SEPTICEMIA,    AND    PYEMIA.  69 

in  the  majority  of  cases  of  septicaemia  or  pyaemia,  as  well  as  the  evident 
existence  of  secondary  inflammations  and  metastatic  deposits  in  the  latter 
disease,  proclaim  the  nature  of  the  affection  with  no  doubtful  voice.  It  is, 
however,  difficult  at  times  to  certify  that  visceral  symptoms  are  really 
due  to  metastatic  abscesses,  and  not  to  simple  inflammatory  lesions. 
Many  of  the  symptoms  of  typhoid  fever  resemble  those  of  septictemia, 
because  the  intestinal  lesions  of  the  former  disease  lead  to  septic  infection 
of  the  patient. 

Treatment. — The  indications  of  treatment  are  to  remove  the  exciting 
causes  of  septic  conditions  by  general  local  prophylactic  measures,  and 
to  support  the  system  until  the  poison  is  eliminated.  An  abundance  of 
fresh  air,  sequestration  of  pysemic,  erysipelatous  and  similar  patients, 
sterilization  of  clothing  and  instruments  that  possibly  contain  septic 
germs,  and  the  aseptic  or  antiseptic  ti'eatment  of  all  wounds,  are  im- 
portant factors  in  preventing  the  occurrence  of  the  disease  in  hospitals. 
These  are  general  measures  to  preclude  the  advent  of  the  disease  among 
patients  with  operative  or  accidental  wounds  who  are  to  be  subjected  to 
the  influences  of  hospital  wards.  It  is  especially  necessary,  moreover, 
so  to  treat  every  patient  that  he  may  not  be  liable  to  self-infection  from 
generation  of  the  septic  poison  in  the  discharges  of  his  own  wound. 
Hence,  union  by  first  intention,  or  by  rapid  and  healthy  granulation,  is 
to  be  obtained  as  quickly  as  possible.  The  surgeon  must  be  on  his  guard, 
however,  lest  in  this  endeavor  he  allow  purulent  accumulations  and 
bun-owing  to  occur  ;  for  pus  contained  in  irregular  cavities  exposed  to 
the  air  soon  decomposes,  and  putridity  is  the  fertile  source  of  septic 
infection.  Hence,  free  incisions,  counter-openings,  and  perfect  drainage 
of  the  lowest  depths  of  the  wound,  with  copious  antiseptic  affusions, 
are  absolutely  essential.  Free  laying  open  of  irregular,  lacerated,  and 
dirty  wounds,  even  before  suppuration  occurs,  especially  if  serous  cavities 
be  involved,  is  often  the  most  scientific  treatment,  although,  to  the  inex- 
perienced mind,  it  seems  like  protracting  the  cure  by  increasing  the 
wound  surfaces.  Such  wounds  should  be  thoroughly  washed  out  with 
sublimate  solution  (1 :  500  to  1  :  5000),  carbolized  water  (1  :  40),  solu- 
tions of  chloride  of  zinc  (1 :  100  or  1  :  50),  or  some  similar  antiseptic 
lotion,  before  suturing  or  dressing.  In  very  large  wounds  corrosive  sub- 
limate may  cause  toxic  symptoms  if  used  in  strong  solution.  Shreds 
of  devitilized  tissue,  decomposing  blood-clots,  and  unhealthy  pus  confined 
in  any  portion  of  such  wound  will  cause  septic  or  pysemic  symptoms  with 
great  readiness.  All  abscesses  forming  in  the  neighborhood  of  the 
original  wound  must  be  opened  promptly.  The  method  of  dressing 
wounds  must  be  that  known  as  the  aseptic  or  antiseptic  method,  of 
which  there  are  many  variations  fulfilling  the  same  conditions.  Mopping 
the  surface  with  undiluted  carbolic  acid  may,  perhaps,  become  an  im- 
portant preventive  agent  in  certain  cases,  where  infection  is  feared,  as  it 
probably  seals  the  vessels  and  hinders  septic  absorption. 

To  support  the  system  after  septic  infection  has  occurred,  tonics,  stimu- 
lants, and  nutritious  food  must  be  employed.  There  is  no  specific  remedy 
available.  At  first  a  laxative  may  or  may  not  be  required.  The  appear- 
ance of  the  tongue  and  state  of  the  bowels  indicate  or  contra-indicate  its 
use.  Quinia  (gr.  ij)  and  tincture  of  chloride  of  iron  (it|^  xx)  every 
three  or  four  hours ;  brandy  in  amounts  varying  from  two  to  six  fluid- 
ounces  daily,  and  opium,  if  pain  demands  it,  in  one  or  two-grain  doses 
every  second  or  fourth  hour,  will  be  the  line  of  medication  suited  to  the 
majority  of  cases.     Frequent  administration  of  cream,  milk,  and  animal 


70  SAI'R^.MIA,    SEPTICEMIA,    AND    PYEMIA. 

broths,  given  in  small  amounts,  day  and  night,  is  absolutely  essential.  An 
astringent  combined  with  opium  (as  for  example,  tannic  acid  gr.ij,  opium 
gr.  j,  capt-icum  gr.  1);  atropia  sulpliate  gr.  ^^■,  turpentine  ni  x,  or  some 
other  remedy  ,  may  be  needed  at  varyini,^  intervals,  to  combat  diarrhoea, 
profuse  sweating,  or  dry  tongue  and  tympanites.  In  fact,  symptou)s  must 
be  met  by  appropriate  remedie?;,  since  no  speciKc  to  eliminate  the  p(jison 
is  of  recognized  value,  though  many  have  been  advocated. 


CHAPTER    lY. 

SCROFULA   AND   TUBERCULOSIS. 

Definition. — Scrofula,  or  struma,  was  formerly  believed  to  be  a  consti- 
tutional condition  in  which  there  existed  an  abnormal  tendency  to  inflam- 
mations of  unusual  chronicity,  and  in  which  the  inflammatory  products 
were  not  readily  absorbed,  but  infiltrated  the  tissues  and  underwent 
cheesy  degeneration.  These  inflammations  occurred  either  idiopathically 
or  after  slight  injuries,  and  were  especially  prone  to  attack  the  lymphatic 
glands,  the  skin  and  mucous  membranes,  the  serous  membranes,  and  the 
bones  and  joints. 

We  now  know  that  scrofula  is  simply  tuberculosis,  usually  of  the  infil- 
trated and  not  of  the  nodular  form  ;  and  that  it  is  due  to  the  bacillus 
tuberculosis.  The  structures  mentioned  above  are  obviously  those  into 
which  the  parasitic  plant  most  readily  penetrates.  Microscopical  exami- 
nation of  scrofulous  lesions  shows  the  presence  of  typical  tubercles  and  the 
bacillus.  It  is  a  well-known  clinical  fact  that  miliary  tubercles  may 
result  from  scrofulous  lesions.  Lupus,  also,  is  probably  simply  an  example 
of  cutaneous  tuberculosis.  It  is  thus  seen  that  these  three  conditions, 
which  formerly  were  considered  separate  diseases,  are  now,  according  to 
recent  pathological  research,  included  in  one  category. 

Tuberculosis  is  an  infective  disease  due  to  a  bacillus.  Its  lesions  may 
be  so  numerous  as  to  justify  the  term  general  tuberculosis,  or  there  may 
be  a  single  lesion,  when  it  is  known  as  local  tuberculosis.  The  original 
infection,  of  course,  is  usually  a  single  lesion,  but  it  is  often  the  focus 
from  which  further  infection  originates,  causing  lesions  in  distant  parts  of 
the  body. 

Chronic  inflammation  due  to  the  bacillus  tuberculosis  may  give  rise  to 
small  nodular  m.asses.  or  may  assume  the  infiltrating  form.  The  inflam- 
matory lesions  due  to  the  antagonism  of  the  tissue  to  the  raicrobic  irrita- 
tion, are  small  masses  of  granulation  tissue  called  tubercles,  because 
they  usually  make  small  shot-like  protuberances.  Tubercles  are  de- 
scribed from  their  color  as  gray  and  yellow;  the  latter,  however,  are 
simply  a  later  stage  of  the  former,  because  the  gray  tubercles  usually 
finally  undergo  cheesy  degeneration. 

Tubercles  are  found  in  the  skin,  the  subcutaneous  tissues,  the  mucous 
membranes,  the  serous  membranes,  the  cancellated  structure  of  bones, 
the  lymp)hatic  glands,  the  lungs,  the  liver  and  testicles;  in  fact,  in  al- 
most every  structure,  though  most  frequently  in  those  just  mentioned. 

Pathology. — Gray  or  miliary  tubercles  are,  according  to  my  concep- 
tion of  prevalent  pathological  views,  minute  inflammatory  shot-like 
tumors  or  growths,  not  larger  than  a  millet-seed,  consisting  of  granulation 
tissue  and  resulting  from  infection  of  the  system  by  the  bacillus  tuber- 
culosis. The  general  infection  occurs  through  the  blood  and  lymph- 
atic currents,  and  is  due  to  the  transfer  of  the  organisms  from  some 
local  tubercular  inflammation  which  may  have  remained  many  months 
without   iufecting    the   rest  of  the  body.     The  gray  tubercles  undergo 


72  SCROFULA    AND    T  UR  E  KG  U  LOST  S. 

cheesy  degeneration,  as,  indeed,  may  any  structures  which  have  little  vas- 
cularity jind  great  abundance  of  cells,   and   become   yellow   tubercles. 

Miliary  tubercles  may  not  only  be 
Fig.  7.  due     to     some     previously  existing 

caseous   tubercular   centre,  but   be- 
come caseous  themselves.     The  term 
yellow  tubercle  is  often   applied  to 
cheesy  masses,  without  much  refer- 
ence to  their  causation,    (xray  tuber- 
cles show  microscopically  a  network 
of  large,  branched,  many-nucleated 
cells,    called    giant-cells,    associated 
with  a  small-celled  structure  resem- 
bling   adenoid    tissue.      Differences 
occur,  however,  with  variation  in  lo- 
cality   of    the    tuberculous    lesions. 
Ti.i.ercle  bacilli  in  giant-cell.    Specimen     The  "bacilli  are  found  within  the  tu- 
from  tuberculosis  in  a  horse.  (Gref.n.)        bercle,  and  especially  in  the  giant- 
cells.      Persons   who   may   have   an 
inherited  proneness  toinflammatory  affections,  characterized  by  chronicity 
and  by  products  containing  many  cells  and  tending  to  caseation,  would 
be  most  liable  to  afford  a  suitable  soil  for  the  tubercle  bacillus,  and  thus 
become  tuberculous.      They  are  those  who  were  formerly  called  scrofu- 
lous or  strumous.    Chee.\v  or  calcareous  degeneration,  encapsulation  of  tiie 
bacilli  by  fibroid  or  scar  tissue,  and  breaking  down  into  puriform  fluid, 
causing  the  so  called  chronic  abscess,  may  occur  as  secondary  changes. 

Causes. — It  was  formerly  taught  that'  the  tendency  to  such  inflamma- 
tions was  often  inherited,  constituting  hereditary  scrofula,  but  that 
a  chronic  inflammation  might  cause  infection  and  tuberculosis  in  one 
who  had  not  previously  shown  any  caseous  degenerative  changes,  and  who 
had  no  inherited  predisposition  thereto.  This  was  denominated  acquired 
scrofula.  A  chief  cause  of  iidierited  scrofula  was  thought  to  be  syphilitic 
ancestry,  which  established  the  tendency  to  chronic  and  cellular  forms  of 
inflammation.  The  acquired  tendency  to  scrofulous  aflections  was  at- 
tributed to  improper  nutrition,  often,  perhaps,  due  to  feeding  infants  on 
the  milk  of  tuberculous  cows,  to  impure  air,  exposure,  and  overwork. 
We  now  know  that  it  is  infection  by  a  vegetable  parasite  which  causes 
these  anomalies,  and  that  the  fungus  produces  its  effects  most  surely  when 
it  finds  a  suitable  soil  for  its  germination.  Such  a  soil  is  furnished  by 
the  ill-nourished,  the  weak,  whose  tissues  prove  least  resistant  to  my- 
cotic invasion.  Scrofula  and  tubercidosis  exist  much  more  frequently 
among  children  and  young  adults,  but  no  age  is  exemi)t  from  such 
affections. 

Symptoms. — The  aflections  which  are  apt  to  occur  among  tho.se  called 
tuberculous  are  characterized  by  protracted  inflammation  and  degenera- 
tion of  the  tissue,  often  giving  rise  to  a  puriform  liquid.  The  products  of 
this  chronic  inflammation,  instead  of  being  i-apidly  absorbed,  accumulate 
and  often  become  cheesy.  Enlarged  lymijhatie  glands,  which  may  de- 
generate into  caseous  masses,  or  soften  and  give  ri.se  to  thin  curdy  puri- 
form fluid,  are  frequent.  Other  lesions  are  chronic  catarrh  of  the  various 
mucous  membranes;  cold  abscesses  which  burrow,  and,  discharging,  leave 
ulcers  with  livid,  ragged  edges,  that  in  turn  are  followed  by  irregular  and 
puckered  cicatrices  ;  phthisis,  synovitis,  and  arthritis  ;  caries  and  necrosis; 
corneitis  ;  and  ulcers  and  cutaneous  inflammations,  often  called  scrofulides. 


SCROFULA    AND    TUBERCULOSIS.  73 

Attempts  to  define  the  physical  and  mental  characteristics  of  those  liable 
to  suiFer  from  strumous  disease  are  valueless,  because  all  temperaments 
may,  as  we  now  know,  become  tuberculous  from  infection  with  the  bacillus 
tuberculosis. 

Treatment. — Inherited  predispositions  to  tubercular  infection  must  be 
so  treated  as  to  prevent  the  possibility  of  infection  ;  when  infection  has 
occurred  the  original  lesion  must  be  so  managed  as  to  obviate  general 
infection.  The  best  possible  condition  of  nutrition  must  be  obtained  by 
good  diet,  warm  clothing,  and  out-of-door  life  in  equable  climates,  com- 
bined with  bathing  and  friction  of  the  skin.  The  digestion  must  be  care- 
fully watched,  and  regulated  by  alkalies,  laxatives,  mineral  acids,  tonics, 
and  proper  exercise.  Each  case  demands  especial  study.  Cod-liver  oil, 
syrup  of  iodide  of  iron,  quinia,  iodide  of  potassium,  iodoform,  iodine, 
arsenic,  mercury,  chlorate  of  potassium,  and  rarely  alcohol,  are  the  medi- 
cinal agents  usually  required,  but  they  are  secondary  to  the  hygienic 
measures  mentioned.  To  hasten  the  cure  of  the  chronic  inflammations, 
local  measures,  such  as  recommended  under  that  heading,  are  required. 
Early  and  complete  excision  of  the  tubercular  lesion  is  often  the  safest 
course.  The  pus  of  abscesses  is  sometimes  absorbed,  but  it  is  better  to 
evacuate  it  with  a  knife  or  aspirator  than  to  have  the  deformed  cicatrix 
due  to  spontaneous  evacuation.  Glandular  masses,  if  small,  may  be 
enucleated.  To  avert  an  impending  scrofulous  or  tuberculous  general 
infection,  excision  of  bone,  arthrectomy  of  a  joint,  or  even  amputation  of 
a  limb,  may  be  necessary.  Such  operations,  however,  must  not  be  done 
too  hastily,  though  in  certain  cases  their  expediency  is  unquestioned  as  a 
factor  in  preventing  or  ameliorating  an  acquired  tubercular  habit.  The 
deformity  due  to  irregular  cicatrices  after  abscess  of  cervical  glands  may 
be  relieved  by  dissecting  out  the  elevated  masses,  and  by  sliding  skin  over 
the  depressed  scars  so  as  to  make  a  level  surface  with  a  single  white  linear 
scar. 


CHAPTER    Y 


SYPHILIS. 

Defin'itiox. — Syphilis  i.s  a  constitutional  disease  resulting  from  a 
blood  poison,  of  unknown  nature,  introduced  by  inoculation  or  by  heredi- 
tary transmission.  The  acquired  form  has  a  period  of  incubation,  and 
appears  to  be  self-protective — that  is,  a  person  who  has  once  l)een  inocu- 
lated is  not  liable  to  be  affected  by  subsequent  exposure  to  the  virus.  The 
words  venereal  disease  are  often  used  to  include  syphilis,  chancroid  dis- 
ease (improperly  called  local  syphilis),  and  urethritis.  The  term  should 
be  rejected  because  these  affections  are  by  no  means  always  acquired 
through  sexual  intercourse,  and  are  so  mutually  distinct  that  any  classi- 
fication of  them  under  one  heading  induces  mistaken  ideas  of  pathology. 

While  discussing  syi)hilis  and  its  primary  lesion,  hard  chancre,  I  shall 
speak  incidentally  of  chancroid  disease,  or  soft  chancre,  which  is  a  dis- 
tinct affection,  resembling  the  first  manifestation  of  syphilis,  but  not 
resulting  from  constitutional  infection.  This  disease,  as  well  as  urethritis, 
or  gonorrha?a,  will  be  fully  considered  under  local  diseases  of  the  genito- 
urinary apparatus,  where  they  properly  belong ;  though  chancroid  is  by 
some  described  in  this  connection  because  of  its  important  differential 
diagnosis  from  syphilis. 

Causes. — Syphilis,  when  not  congenital,  can  only  be  produced  in 
healthy  individuals  by  inoculation  witli  the  specific  virus.  Inoculation 
may  occur  directly,  from  contact  usually,  of  an  abraded  surface,  with  the 
secretions  of  primary  or  secondary  manifa-^tations  of  the  disease  situated 
upon  another  person,  or  indirectly  by  the  discharges  of  such  lesions  being 
transferred  by  means  of  drinking-cups,  surgical  or  dental  instruments, 
t)bacco-pipes,  towels,  etc.  In  the  vast  majority  of  cases  of  acquired 
syphilis,  inoculation  occurs  during  sexual  intercourse,  from  chancres  or 
mucous  patches  upon  the  genitals.  Inoculation  may  occur  from  the 
blood  of  syphilitics,  taken  during  the  eruptive  period  of  the  disease,  being 
introduced  [into  the  system  by  vaccination,  skin-grafting,  and,  perhaps, 
also  by  contact  with  the  menstrual  blood  of  women  infected  with  consti- 
tutional syphilis,  who  have  at  the  time  of  coitus  no  lesion  of  the  genital 
organs.  It  is  doubtful  whether  the  saliva,  milk,  and  semen  can  cause 
syphilis,  unless  mixed  with  the  discharges  and  blood  coming  from  mucous 
patches  or  other  lesions.  The  discharge  from  tertiary  ulcers  or  gummy 
tumors  is  not  capable  of  inoculating  other  persons.  It  is  not  absolutely 
necessary  that  a  break  or  abrasion  of  the  skin  or  mucous  membrane  exist 
to  permit  admission  of  the  virus.  A  woman,  previously  healthy,  may, 
it  is  said,  become  infected  from  carrying  a  foetus  which  is  syphilitic  from 
the  semen  being  furnished  by  a  syphilitic  father.  The  woman,  if  this  is 
true,  is  infected  by  the  man,  not  directly,  but  secondarily  through  the 
medium  of  the  foetus  and  the  placenta. 

A  prolific  cause  of  syphilis  is  heredity.  Two  syphilitic  parents  are 
almost  certain  to  have,  if  repeated  abortions  do  not  interfere,  children 
who  subsequently  exhibit  symptoms  of  constitutional  syphilis.     If  only 


SYMPTOMS.  75 

one  parent  is  syphilitic  the  child  is  less  liable  to  infection,  particularly  if 
the  diseased  parent  is  the  father.  Hence  marriage  of  syphilized  subjects 
is  to  be  discouraged ;  though  if  the  acquired  disease  was  mild  and  well 
treated  and  no  lesions  have  appeared  for  one  or  two  years,  the  risk  of  con- 
taminating the  wife  or  husband  and  of  producing  children  with  syphilitic 
constitutions  is  reduced  to  a  minimum.  Scrofulous  or  tuberculous  chil- 
dren are  frequent  witnesses  of  such  marriages  which  have  not  in  truth 
produced  true  hereditary  syphilis  ;  but  have  brought  forth  a  posterity 
liable  to  chronic  inflammations,  caseation,  and  tubercle  infection. 

The  cause  of  syphilis  is  almost  certainly  a  microorganism,  though  up 
to  this  time  it  has  not  been  definitely  and  certainly  found. 

Clinical  History. — A  study  of  the  symptoms  of  syphilis  reveals  the 
existence  of: 

1.  A  stage  of  incubation  lasting  two  or  three  weeks,  followed  by 

2.  A  primary  stage,  marked  by  chancre  and  bubo,  which,  at  the  end  of 
two  or  three  months,  is  followed  by 

3.  A  secondary  stage,  characterized  by  eruptions  and  inflammations  of 
the  mucous  membranes,  which,  at  the  end  of  six  or  twelve  months  or  a 
longer  period,  is  succeeded  by 

4.  A  tertiary  stage,  exhibiting  itself  by  ulcers  and  other  severe  cuta- 
neous lesions,  bone  diseases  and  gummy  deposits,  and  which  often  is  fol- 
lowed, if  the  patient  marries,  by  what  may  be  called 

5.  A  quarternary  stage,  exhibited  in  his  children.  The  quarternary 
form,  or  hereditary  syphilis,  presents  lesions  similar  to  the  secondary  and 
tertiary  stages  of  acquired  syphilis. 

Symptoms. —  Tlie  stage  of  incubation  is  the  period  between  the  time  of 
contact  with  the  virus  and  the  appearance  of  chancre.  It  varies  greatly, 
but  lasts,  on  the  average,  two  or  three  weeks.  It  often  is  represented  by 
the  patient  to  be  longer  than  this,  because  he  feils  to  recognize  the  advent 
of  a  small  chancre 

During  any  portion  of  the  incubation  period  local  inflammation  of  the 
parts  may  arise,  due  to  simultaneous  contact  with  irritating  discharges 
(Chancroid,  etc.),  or  to  injury,  which  has  no  pathological  relation  to  the 
syphilitic  chancre  that  is  subsequently  developed.  The  local  disease  may 
persist  even  after  the  stage  of  incubation  has  passed  and  the  initial  lesion 
(chancre)  is  exhibited. 

If  the  syphilitic  inoculation  was  effected  at  the  same  point  at  which  the 
inflammatory  ulceration,  due  to  irritating  discharges,  is  in  progress,  the 
patient  Avill  have  the  two  lesions  combined  at  that  locality.  This  fact  has 
induced  many  observers  to  believe  erroneously  that  chancroid  may  be 
followed  by  syphilis. 

Primary  stage. — The  initial  lesion  of  acquired  syphilis  is  always  chancre, 
which  is  soon  followed  by  lymphatic  involvement,  causing  adenitis.  The 
inflamed  and  enlarged  glands  constitute  a  swelling  or  tumor,  called  bubo. 
It  must  be  remembered  that  when  chancre  appears  the  patient  has  already 
been  syphilitic  for  two  or  three  weeks ;  that  is,  daring  the  time  of  the 
incubation  stage.  The  chancre  is  the  result  of  his  syphilitic  condition, 
and  is  not  a  local  sore,  which  generates  the  poison  that  infects  the  system. 
The  chancre,  which  must  not  be  confounded  with  the  chancroid  sore 
(chancroid,  soft  chancre,  non-infecting  chancre),  presents  different  appear- 
ances, according  to  its  situation  and  the  depth  of  the  tissue  involvement. 
Very  frequently  it  is  a  small,  superficial  papule,  having  a  reddish  color 
and  a  circularly  or  eliptically  ulcerated  apex.  Sometimes  there  is  no 
ulcer  whatever,  but  it  is  rare  that  some  ulceration  does  not  appear.     It  is 


76  SYPHILIS. 

probal)lc  tliat  the  ulceration  is  usually  due  to  infection  of  the  surface  of 
the  syphilitic  lesion  by  pus  bacteria.  Abrasion,  perha[)s,  removes  the  epi- 
dermis from  the  papule,  and  pyogenic  organisms  infect  the  part  so  that 
suppuration  and  ulceration  occur.  When  the  ulcer  exists  it  is  not  much 
excavated,  and  secretes  a  serous  fluid,  containing  epithelial  and  other 
particles,  but  no  pus,  unless  active  inflammatory  processes  have  been 
developed  by  irritation.  The  papule,  with  or  without  ulceration,  has  at 
its  base  a  thin  layer  of  hardened  tissue,  which  is  sharply  defined,  and 
resembles  to  the  touch  a  disk  of  cartilage  or  parchment,  buried  under  the 
skin.  This  induration  is  less  apparent  when  the  chancre  is  located  on  a 
mucous  than  when  on  a  cutaneous  surface,  and  in  some  cases  does  not  per- 
sist long.  At  other  times  the  chancre  is  a  deep  ulcer,  with  elevated  edges 
and  a  surface  covered  Avith  a  sloughing  material ;  still  the  discharge  is 
not  purulent,  but  watery  and,  perhaps,  slightly  sanguinalent.  The  indu- 
ration is  deep  and  slightly  outlined,  and  gives  the  sensation  of  a  split  pea 
between  the  finger-tips.  This  hardening  lasts  a  long  time  even  after  the 
ulcer  has  been  healed  ;  but,  finally,  when  cicatrization  and  absorption 
have  occurred,  there  remains  a  cicatrix  with  comparatively  little  depres- 
sion. The  ulceration  does  not  destroy  the  tissue  of  the  part  as  much  as  it 
appears  to  do,  since  it  is  the  newly-formed  inflammatory  lymph  that  disin- 
tegrates. 

Both  these  forms  are  true  chancres,  but  the  deep  ulcer  seems  to  be  due 
to  a  more  virulent  infection,  as  it  appears  sooner  after  inoculation  than 
the  superficial  chancre,  and,  as  a  rule,  does  not  follow  inoculation  from 
secondary  syphilis,  which  is  more  apt  to  cause  superficial  chancre,  such  as 
described  above.  Either  form  of  chancre  may  assume  phagedenic  action 
under  local  irritation,  or  on  account  of  a  depressed  .state  of  the  system  of 
the  patient,  such  as  struma  and  scurvy. 

The  secretions  from  these  indurated,  hard,  or  infecting  chancres,  whether 
superficial  or  deep,  will  not  produce  similar  sores  when  applied  to  other 
parts  of  the  patient's  body,  for  he  is  protected  against  further  syphilitic 
inoculation.  How  long  this  protection  lasts  is  not  definitely  understood. 
On  this  account  chancre  is  single,  unless  inoculation  at  several  points  has 
occurred  at  the  same  time. 

Coincident  with  the  stage  of  induration  of  chancre,  enlargement  and 
induration  of  the  nearest  lymphatic  glands  appear,  constituting  the  syphi- 
litic bubo.  These  bubos  are  usually  situated  in  the  groin,  because  the 
common  location  of  the  chancre  is  upon  the  genitals.  Bubos,  however, 
are  found  in  the  axilla,  above  the  internal  condyle  of  the  humerus,  under 
the  jaw  and  elsewhere,  according  to  the  position  of  the  chancre.  If  the 
initial  lesion  is  near  the  middle  line,  a  bubo  will,  probably,  be  found  on 
both  sides.  If  the  lymphatic  vessels  from  the  inoculated  spot  lead  to 
internal  lymphatic  glands,  as  in  uterine  chancre,  no  external  bubo  will  be 
manifested.  Induration  of  the  glands  is,  probably,  always  present  in 
syphilis,  but  cannot  occur  unless  chancre  has  preceded  it.  Syphilitic 
bubo  appears,  about  three  weeks  after  inoculation,  as  a  chain  of  hardened 
and  enlarged  glands,  which  are  painless,  or  netirly  so,  and  show  no 
tendency  to  suppuration.  The  inflammation  aflects  the  glands  only,  and 
not  the  surrounding  tissue,  hence  they  retain  their  characteristic  almond 
shape,  and  do  not  suppurate  unless  there  be  some  cause  of  pyogenic  infection, 
such  as  co-existing  chancroid  disease,  or  an  infected  wound.  Then  the  sup- 
puration is  not  syphilitic,  though,  if  due  to  chancroid,  the  pus  may  have 
the  contagious  properties  of  that  /(o«-syphilitic  sore.  If  it  be  due  to  other 
inflammatory  causes,  the  pus  is  as  innocent  as  the  pus  from  common  acute 


SYMPTOMS.  77 

abscesses,  or  ordinary  so-called  sympathetic  suppurating  buboes  ;  that  is, 
it  contains  pus  organisms,  but  not  the  syphilitic  poison. 

The  chronic  and  indurated  bubo  of  syphilis  may  continue  for  many 
months  after  the  chancre  has  disappeared.  The  clinical  history  of  true 
syphilitic  bubo  is  very  different,  as  will  hereafter  be  seen,  from  that  of 
bubo  following  chancroid  disease. 

/Secondary  stage. — -About  six  weeks  after  the  appearance  of  the  chancre, 
the  patient  becomes  more  or  less  feverish,  has,  perhaps,  headache  and 
general  uneasiness  of  an  indefinite  character,  and  then  discovers,  in  the 
course  of  five  or  six  days,  the  existence  of  an  eruption,  sore-throat,  mucous 
patches,  cervical  adenitis,  falling  of  the  hair,  or  iritis.  These  are  the 
symptoms  of  the  secondary  stage,  which  usually  occurs  at  the  time  men- 
tioned, and  is  preceded  by  the  prodromes  described.  It  may  be  delayed 
until  the  sixth  month,  and  often  overlaps  the  period  of  primary  syphilis, 
which  is  prolonged  by  imperfect  resolution  of  the  chancre  and  bubo. 

The  cutaneous  lesions  of  syphilis  are  called  syphilides  or  syphiloderms, 
whether  occurring  as  symptoms  of  the  secondary  or  tertiary  stages.  In  sec- 
ondary syphilis,  the  eruption  is  usually  macular  or  papular  in  form  ;  though 
the  scaly,  vesicular,  pustular  and  tubercular  syphiloderms  may  occur.  The 
last  two  varieties  are  more  common  in  the  later  periods  of  secondary  syphi- 
lis, or  in  the  tertiary  stage.  Syphilitic  skin  affections  usually  become  some- 
what brownish  in  color  about  the  time  of  their  disajDpearance,  are  accom- 
panied by  very  little  itching,  often  present  several  varieties  at  the  same 
time,  and  are  not  confined  to  a  single  portion  of  the  patient's  body. 
Mucous  tubercles  or  patches  are  flattened  and  elongated  elevations,  a 
quarter  or  half  an  inch  in  diameter,  found  on  the  mucous  surfaces,  at  the 
muco-cutaneous  junctions  or  where  the  skin  is  very  delicate,  and  covered 
by  a  whitish  exudate.  They  appear  at  first  as  reddish  elevations,  from 
which  the  cuticule  is  removed,  and  upon  which  the  exudate  soon  occurs, 
giving  the  surface  an  appearance  similar  to  that  produced  by  touching 
mucous  membrane  "with  nitrate  of  silver.  The  sore  mouth  and  throat  of 
secondary  syphilis  are  due  to  these  mucous  patches,  to  superficial  inflam- 
mation and  ulceration,  or  to  a  combination  of  these  lesions. 

Inoculation  of  syphilis  occurs  more  frequently  from  these  mucous  patches 
about  the  genitals  and  mouth  than  from  the  secretions  of  chancre  itself. 
Inflammation  and  chronic  enlargement  of  the  lymphatic  glands,  especially 
of  those  situated  along  the  postex'ior  margin  of  the  sterno-mastoid  muscle, 
are  very  frequent  symptoms  of  the  secondary  stage.  These  have  no 
necessary  relation  to  the  existence  of  marked  cutaneous  lesions  in  the 
neighborhood.  Falling  of  the  hair  of  the  scalp  and  other  regions,  and 
inflammation  of  the  iris  are  frequently  present  in  secondary  syphilis.  The 
papular  eruption  often  occurs  as  an  accompaniment  of  the  iritis.  Other 
symptoms  may  present  themselves  in  the  secondary  stage,  but  the  most 
common  have  been  mentioned. 

Tertiary  stage. — There  is  no  distinct  separation  between  the  secondary 
and  tertiary  stages,  but  the  latter  is  characterized  by  more  chronic  and  less 
contagious  lesions,  which  affect,  as  a  rule,  the  dee]3er  tissues  of  the  body. 
It  is  convenient  to  consider  lesions  originating  after  the  lapse  of  six 
months  as  tertiary  symptoms.  Tertiary  symptoms  are  not  exhibited  in 
all  cases,  because  the  disease  may  be  so  mild  or  so  judiciously  treated  that 
it  subsides  or  becomes  latent  with  the  disappearance  of  the  secondary 
troubles.  Very  often,  however,  the  disease  remains  in  abeyance  for  many 
months  or  years,  and  then  tertiary  lesions  supervene. 

The  lesions  produced  by  tertiary  syphilis  may  be  classified  under  the 


78 


SYPHILIS. 


folloAviiiir  heads  :  1,  Fibroid  dogcnerations  ;  2,  2:ummv  deposits  ;  3,  changes 
in  the  arterial  walls.  The  fibroid  indurations  oceur  in  limited  areas  sur- 
rounded by  normal  tissue,  and  are  found  in  periosteum,  sheaths  of  nerves 
and  of  organs,  and  in  musele.  Gummy  tumors  or  deposits  are  yellowish 
masses  of  firm  consistence,  due  to  degenerated  cell-products,  surrounded 
by  a  hbrous  area,  which  is  in  turn  encircled  by  a  cellular  and  vascular  zone 
intimately  adherent  to  adjacent  structures.  They  are  the  most  character- 
istic formation  of  syphilis  and  occur  in  the  tegumentary  structures,  mus- 
cles, fasciie,  bones,  and  internal  organs.  They  may  become  caseous,  but 
often  in  a  manner  not  well  understood,  cause  suppuration  around  them- 
selves, break  down  and  cause  the  deep  intractable  ulcers  of  tertiary 
svphilis.  The  change  in  arterial  walls  occurs  in  the  inner  coat  and  causes 
diminution  in  calibre,  which  interferes  with  circulation  and  may  induce 
degenerative  changes.  The  tertiary  syphiiodernis  are  usually  pustular, 
tubercular  or  ulcerous.  The  ulcerations  and  suppurations  found  in  syph- 
ilis are  probably  the  result  of  the  low  vitality  of  the  cells,  affording  a 
place  of  least  resistance  for  the  harmful  localization  of  pyogenic  fungi 
circulating  in  the  blood-streatu.  The  germs  cause  suppuration  there,  when 
to  healthy  tissues  they  would  be  unable  to  do  injury.  The  rupial  ulcer 
with  its  acuminated  scab  is  especially  characteristic,  as  are  the  deep 
ulcers  due  to  destructive  changes  in  gummy  tumors.  Similar  lesions  of 
the  oral  and  other  mucous  membranes  are  frequent.  Periostitis,  oste- 
itis, nodes  due  to  lymph  or  gummy  deposits  under  the  periosteum,  and  all 
causing  bone-pains  (osteoco])ic  pains)  especially  at  night;  caries  and 
necrosis;  iritis,  retinitis  and  choroiditis;  falling  of  the  hair;  onyxitis; 
orchitis:  cerel)ral  and  spinal  inflammations;  and,  in  fact,  inflammation 
of  any  organ  or  tissue  may  be  induced  by  constitutional  syi)hilis.  JNIany 
of  these  lesions  depend  on  the  deposition  of  gummy  material,  others  are 
due  to  the  fibroid  and  arterial  changes  mentioned. 


Fig.  y. 


Fig.  S. 


Uf>per  incisors  of  boy  with  symptoms  of 
inherited  syphilis  from  infancy.  Typical 
notches. 

Quarternary  stage. — This  seems  to 
me  a  good  name  to  apply  to  heredi- 
tary syphilis,  though  1  admit  that 
syphilitic  children  may  be  born  to 
parents  who  have  not  yet  advanced 
beyond  the  secondary  stage.  It  is 
unnecessary  to  discuss  the  method 
by  which  children  inherit  the  syphi- 
litic cachexia,  but  it  is  recognized 
that  the  disease  is  more  certainly 
derived  from  a  syphilitic  mother 
than  from,  a  syphilitic  father,  and 
from  two  more  certainly  than  from 
one  syphilitic  parent. 
The  child  may  not  present  any  di.^tinctive  symptoms  until  a  few  weeks 
after  birth,  when  its   unhealthy  looking    and  shrivelled  skin,  its  agtd 


Notched   teeth 
Boy,  ten    years. 


of    hereditary    syphilid. 

who  had  periostitis  of 
tibia.  Lower  teeth  show  normal  serrations 
of  second  dentition,  and  are  elongated, 
probably  because  the  imperfect  upper  teeth 
do  not  oppose  them. 


DIAGNOSIS.  79 

appearance,  the  nasal  catarrh  and  stomatitis  due  to  the  inflamed  mu- 
cous membranes,  and  the  possible  discovery  of  cutaneous  eruptions  or  of 
mucous  patches  about  the  anus  and  genitals  -will  point  unequivocally  to 
its  syphilitic  parentage.  The  syphilis  so  exhibited  is  of  the  secondary 
form  ;  and  by  its  ability  to  inoculate  other  subjects,  and  its  greater  or  less 
protective  power  against  further  inoculation  of  the  same  subject,  it 
proves  its  identity  -with  ordinary  acquired  syphilis. 

If  death  does  not  remove  the  child,  further  secondary  and  tertiary 
symptoms  will  in  time  follow.  Interstitial  keratitis,  periostitis,  bone  dis- 
ease, and  many  tubercular  affections  will  in  time  be  developed.  The  low 
cell-vitality  of  syphilitic  children  makes  easy  the  a.ssaults  of  the  tubercle 
bacillus.  The  resistance  of  healthy  tissues  is  wanting.  The  peculiar 
notched  condition  of  the  upper  central  incisor  teeth  of  the  permanent 
set,  first  described  by  Hutchinson,  of  London,  is  often  seen. 

These  two  teeth,  and  at  times  others,  are  poorly  developed  ;  having  a 
conical  shape  and  a  cutting  edge,  which  is  mari'ed  by  an  irregularly 
bevelled  anterior  surface,  or  even  distinctly  notched  by  the  breaking  away 
of  the  central  portion.  This  notched  condition  must  not  be  confounded 
with  the  normal  serrated  edge  of  newly  extruded  teeth  of  healthy  chil- 
dren. The  teeth  of  syphilitic  children  are  often  irregularly  placed,  and 
look  like  the  end  of  a  screw-driver  or  are  mere  pointed  pegs.  Syphilitic 
women  are  liable  to  abort  frequently  because  of  the  diseased  condition  of 
the  placenta,  and  it  is  only  after  the  woman  has  regained  a  fair  degree 
of  health  that  the  foetus  is  carried  until  full  term. 

Diagnosis. — The  diagnosis  of  syphilis  rests  upon  the  general  clinical 
history  of  the  disease  rather  than  upon  any  one  symptom  or  upon  the 
statements  (if  the  patient.  The  distinction  between  chancre  and  the  local 
affection  called  chancroid  disease  is  often  difficult,  and  at  times  impos- 
sible, unless  time  be  given  to  watch  the  progress  of  the  symptoms.  The 
diagnosis  is  to  be  founded  upon  the  follow^ing  characteristics  : 

Chaacre.  Chancroid. 

Time.— 'So   noticeable   lesion  until  two  or  Irritation  early  and  sore  developed  within 

three  weeks  after  exposure.  a  week  after  exposure. 

^Yio;i6e/'.— Single  unless  several  points  in-  Multiple,    because   pus  is  auto-inoculable 

oculated  at  time  of  exposure.  and  produces  other  ulcers. 

Character. — Papule,  superficial  abrasion.  Ulcer,  with  edges  steep  as  if  a  piece  of 
or  an  elevated  ulcer,  with  edges  sloping  tissue  had  been  punched  out  or  ragged 
towards  center,  which  coalesces  with  ad-  and  irregular  :  does  not  coalesce  with  ad- 
jacent tissue  and  discharges  a  scanty,  jacent  tissue  and  is  covered  with  a  drab- 
serous,  non-purulent  fluid.  Permanent,  colored  deposit.  The  secretion  is  puru- 
indolent,  non-inflammatory  induration  lent,  very  copious,  and  inoculates  sur- 
at  base  of  sore,  feeling  like  a  disk  of  rounding  surfaces,  thus  producing  mul- 
parchment  or  a  split  pea  beneath  the  tiple  chancroids.  Xo  induration.  Liable 
integument.  Xo  tendency  to  phage-  to  phagedena.  Xo  tendency  to  heal, 
dsena.     Heals  spontaneously. 

Bubo. — Always  present,  involves  a  chain  Often  absent,  involves  but  one  gland  and 

of  glands,  IS  indurated,  usually  bilateral,  one  side     Very   prone   to    suppuration, 

and  seldom  suppurates.     If  it  does  sup-  furnishing   pus  which  readily  inoculates 

purate  pus  is  not  inoculable.  and   produces    other    chancroid    ulcers. 

The    suppurating  bubo   is  practically  a 
ehanc2-oid. 

Pathological    nature. — Due    to   a  constitu-  A  local  affection  never  followed  by  consti- 

tional  disease,  which  is  soon  manifested  tutiohal  symptoms  and.  therefore,  does 

by  other  symiDtoms.  Protects  the  patient  not  protect  against  subsequent   inocula- 

from    subsequent     inoculation;     hence,  tion  :  hence,  surgeon  can  produce  many 

surgeon  cannot  produce  another  chancre  other  chancroids   by  inoculating  patient 

on    him    by  inoculation  with   the  dis-  with  pus  from  original  sore, 
charge  from,  the  suspicious  sore. 

This  table  gives  the  usual  clinical  history  of  the  two  affections,  but  it 
must  be  remembered  that  the  time  of  appearance  and  the  physical  char- 


80  SYPHILIS. 

acteristics  may  vary  somewhat.  Thusj,  a  chancre  may  be  so  infecteii  by 
pus  fungi  as  to  furnish  a  purulent  secretion  ;  and  a  chancroid  may  have 
a  sli;^htly  induratetl  base  by  reason  of  repeated  applications  of  caustics. 

Ciiancre  is  to  be  distinguished  from  epithelioma  by  the  earlier  glandular 
involvement  it  causes,  the  effect  of  anti-syphilitic  treatment,  and  the  con- 
comitant constitutional  symptoms.  Many  doubtful  cases  of  cancer  and 
of  chancroid  can  be  diagnosticated  by  the  collateral  evidence  obtained 
from  confrontation  of  the  patient  and  the  person  by  whom  he  is  supposed 
to  have  been  inoculated. 

Secondary  and  tertiary  syphilitic  lesions  are  to  be  diti'ercntiatod  from 
non-specific  affections  by  the  history,  the  co-existence  of  multiple  patho- 
logical changes,  the  exclusion  of  other  causative  factors  and  the  response 
to  anti-syphilitic  remedies. 

Tkk.\tment. — Syphilis  is  a  constitutional  disease  and  demands  general 
treatment.  Cauterization  or  excision  of  the  chancre  is  valueless,  since 
constitutional  symptoms  are  not  the  result  of  the  chancre,  but  the  latter 
is  a  lesion  due  to  general  infection  dating  from  the  time  of  inoculation. 
Hence,  the  local  treatment  of  chancre  should  consist  of  measures  that 
prevent  the  irritation  of  the  ulcer,  such  as  is  caused  by  rubbing  against 
the  clothing  and  infection  with  pyogenic  microbes.  Antiseptic  protection 
of  the  primary  induration  l)ef<)re  the  epithelium  is  abraded  is  eminently 
pro])er.  Cleansing  with  soa])  and  water  and  a  dry  dressing  of  sublimate 
gauze,  so  applied  as  to  permit  urination,  is  judicious  treatment.  Iodo- 
form dissolved  in  collodion  (gr.  x  to  f.^j)  is  a  convenient  application,  as  it 
makes  an  impervious  coating.  It  should  not  be  applied  until  the  sore  is 
made  aseptic  by  washing  with  soap  or  sublimate  solution.  If  the 
chancre  becomes  phagedtenic,  which  is  rarely  the  case,  strong  caustics, 
such  as  undiluted  nitric  or  carbolic  acid  or  nitrate  of  mercury,  may  be 
employed  to  arrest  the  destructive  action.  The  actual  cautery  destroys 
the  microorganisms  better  than  any  of  these.  It  must  be  applied  to  every 
crevice  of  the  sore.  Bubo,  as  a  rule,  demands  no  local  treatment,  for  it 
is  painless  and  merely  an  expression  of  the  constitutional  implication. 
Moreover  local  treatment  is  useless  because  it,  as  a  rule,  effects  no  result. 
If  suppuration  occurs  about  the  indurated  glands,  the  pus  should  be 
evacuated  as  if  the  abscess  were  non-specific,  which,  indeed,  it  really  is. 

The  special  constitutional  remedies  for  syphilis  in  all  its  stages  are 
mercury  and  iodine ;  of  these  mercury  is  probably  the  more  important 
and  efficient.  The  manner  of  using  these  drugs  is  important,  but  the 
preparation  employed  may  vary  with  the  fancy  of  the  surgeon  and  the 
convenience  of  the  patient.  It  is  absolutely  essential  that  the  effect  of 
the  remedy  be  maintained  for  one  or  two  years,  if  the  tendency  to  sec- 
ondary and  tertiary  manifestations  is  to  be  eradicated.  Mercury  is  the 
better  remedy  for  the  primary  and  secondary  lesions,  and  iodine  probably 
the  better  one  for  the  tertiary  affections  ;  though  this  dictum  may  at  times 
be  invalidated  by  individual  experience.  In  the  later  lesions  I  usually 
employ  a  combination  of  both  drugs. 

As  soon  as  the  diagnosis  of  syphilis  is  established,  mercurial  treatment 
is  to  be  instituted,  and,  even  in  doubtful  cases,  I  should  probably  give  the 
]jatient  anti-syphilitic  remedies.  Many,  perhaps  most,  syphilographers 
prefer  to  wait  until  the  diagnosis  of  a  doubtful  sore  is  absolutely  estab- 
lished by  the  occurrence  of  secondary  symptoms.  The  green  iodide  of 
mercury  (often  called  the  protiodide)  may  be  given  in  quarter-grain  pills 
three  times  daily  after  meals  ;  or  a  corresponding  amount  of  blue  pill  or 
calomel  may  be  substituted.     If  it  is  found   in  the  course  of  a  few  days 


TREATMENT.  81 

that  unusual  looseness  of  the  bowels  is  produced,  one  or  two  grains  of 
tannic  acid  or  a  sixth  of  a  grain  of  opium  may  be  added  to  each  pill. 
This  amount  of  mercury  will  probably  be  tolerated  for  several  weeks 
without  causing  tenderness  of  the  gums  or  undue  salivary  excitation.  As 
soon  as  either  of  these  effects  is  induced  the  amount  must  be  decreased  or 
the  drug  entirely  suspended  for  a  week.  In  cases  where  the  disease  is 
violent  in  its  first  manifestations,  an  early  decided  mercurial  impression 
is  necessary.  Blue  pill  in  one  to  three  grains  daily,  or  calomel  to  the 
amount  of  one-half  to  two  grains  daily,  or  a  similar  amount  of  green 
iodide  continued  until  evidences  of  moderate  constitutional  effects  become 
evident,  is  judicious  treatment.  If  no  beneficial  effect  is  observed  from 
ordinary  small  doses,  and  the  condition  of  the  gums  will  warrant  it,  the 
dose  must  be  increased.  In  this  tentative  manner  the  maximum  quantity 
which  the  patient  can  take  Avithout  causing  gastric,  intestinal,  or  oral 
irritability  is  determined.  This  he  must  continue  during  nearly  two 
years,  occasionally  omitting  treatment  for  one  or  two  weeks,  but  never 
suspending  it  entirely,  even  if  no  further  constitutional  symptoms  have 
shown  themselves.  There  is  no  danger  of  taking  these  small  or  tonic 
doses  of  mercury  for  too  long  a  period  in  this  way,  but  there  is  often  a 
tendency  to  tire  of  what  seems  unnecessary  tediousness  of  treatment. 

If  it  is  preferred,  some  of  the  other  mercurial  preparations  may  be 
used,  or  the  agent  may  be  introduced  into  the  system  by  inunction,  fumi- 
gation, hypodermic  injection,  or  suppository. 

For  inunction  thii'ty  or  forty  grains  of  the  officinal  ointment  of  mercury 
may  be  rubbed  into  the  thin  skin  of  the  inner  side  of  the  arms  or  thighs 
at  bedtime.  Fumigation  is  accomplished  by  volatilizing  a  half  drachm 
of  calomel  by  means  of  a  lamp  placed  under  a  metal  plate  upon  which 
the  drug  is  spread.  Any  apparatus  which  will  allow  this  arrangement, 
and  at  the  same  time  furnish  an  atmosphere  warmed  and  filled  with 
steam,  is  all  that  is  required.  The  patient  is  divested  of  clothing,  and 
surrounded  by  a  rubber  cloth  extending  from  his  neck  to  the  floor. 
Under  this  covering  the  genei'ator  of  mercurial  vapor  and  of  steam  is 
placed,  and  thus  the  moistened  cutaneous  surface  is  subjected  to  the  reme- 
dial influence. 

Such  fumigation  may  be  repeated  every  day  for  fifteen  minutes,  and  is 
especially  available  in  syphilitic  skin  affections.  Internal  treatment  may 
be  used  in  conjunction  with  these  mercurial  baths.  The  corrosive  chlo- 
ride of  mercury  in  doses  of  from  one-thirtieth  to  one-tenth  of  a  grain  may 
be  given  hypodermically.  All  these  methods,  however,  are  too  incon- 
venient for  prolonged  use,  and  will  never  supersede  the  ordinary  mode  of 
administration,  except  in  especially  selected  cases.  At  certain  times,  be- 
cause of  the  inefficiency  or  undesirability  of  mercury,  the  preparations  of 
iodine  must  be  utilized.  The  iodides  of  potassium,  sodium,  and  ammo- 
nium are  usually  adopted  because  of  their  cheapness,  convenience,  and 
efficiency.  Iodoform  is  too  offensive  in  odor,  and  many  other  prepara- 
tions are  too  expensive  or  bulky.  The  iodides  seem  more  valuable  in 
the  late  lesions  of  syphilis  than  in  the  primary  and  early  secondary 
affections.  They  are  to  be  given  in  ten  to  thirty  grain  doses  three  or  four 
times  daily,  after  meals,  and  preferably,  perhaps,  in  alkaline  solutions. 
The  sodium  iodide  will  often  produce  less  coryza  and  mucous  irritability 
than  the  commonly  employed  potassium  salt,  though  the  remedial  power 
of  the  drugs  is  about  equal.  Upon  some  persons  the  iodides  act  as  a 
poison,  and  in  very  small  doses  produce  coryza,  conjunctivitis,  cough,  and 
a  papular  eruption.     Usually,  however,  these  disagreeable  effects  can  be 

6 


82  SYPHILIS. 

obviated  by  eoinbining  a  small  amount  of  morphia  with  each  do-se,  or  by 
resorting  to  some  other  preparation  of  iodine. 

Before  leaving  the  constitutional  treatment  of  syphilis,  it  is  necessary 
to  remind  the  reader  that  many  patients  are  so  broken  down  by  the  effects 
of  the  syphilitic  poison,  or  l)y  previous  conditions  of  ill  health,  either  ac- 
tpiircd  or  hereditary,  that  the  use  of  corroborant  remedies  is  imperatively 
(lemanded.  Such  cases  require  (piinia,  iron,  mineral  acids,  stimulants, 
cod-liver  oil,  and  concentrated  food.  It  is  often  j)ossible  to  keep  up  this 
line  of  action  while  administering  the  small  iloses  of  mercury,  or  the 
iodides.  If  these  remedies  seem  to  interfere  with  digestion  and  pnjduce 
amemia,  they  must  be  suspended  or  reduced  in  amount  for  a  time,  and 
the  reliance  of  the  surgeon  be  upon  the  tonic  and  supporting  regimen. 
It  is  a  mistake,  however,  always  to  consider  the  prolonged  course  of  mild 
specific  medication  a  depressing^  agency,  for  in  the  majority  of  cases  it  is 
the  syphilis  that  depresses,  and  the  specifics  which  neutralize  this  poison 
are  really  the  proper  drugs  to  increase  the  health  equation.  Agents 
which  tend  to  eliminate  morbid  matters  from  the  blood  are  doubtless 
valuable ;  hence,  Turkish  baths  and  secretory  stimulants  probably  are 
beneficial  in  the  treatment  of  syphilis. 

.Vgaiu,  it  is  very  often  of  advantage  to  combine  the  mercurial  and 
iodine  treatment  when  either  agent  alone  does  not  beget  favorable  results. 
In  very  late  lesions,  unusually  large  doses  of  iodide  of  potassium,  such  as 
a  half  drachm  or  a  drachm,  largely  diluted  and  taken  after  f){)d  three  or 
four  times  daily,  will  occasionally  work  astonishing  cures  of  painful  con- 
ditions due  to  periostitis  and  nerve  lesions.  I  usually  give  about  thirty 
grains  of  the  potassium  iodide  before  each  meal,  and  a  half  to  one  grain 
of  the  green  iodide  of  mercury  with  a  grain  of  tannic  acid  after  each 
meal.  These  remedies  should  not  be  taken  at  the  same  time,  as  red  iodide 
of  mercury  might  perhaps  be  formed  and  poison  the  patient. 

Hereditary  syphilis  must  be  treated  with  mercury  and  iodine,  combined 
with  or  occa-sionally  replaced  by  tonics,  in  the  same  manner  as  acquired 
svphilis.  The  syrup  of  iodide  of  iron  in  twenty  or  thirty  drop  doses  is 
often  an  eligible  preparation.  Warm  clothing,  good  diet,  and  hygienic 
surroundings  of  tlie  best  character  are  important  factors  in  bringing 
syphilitic  children  to  adult  life.  It  is  probable  that  the  subjects  of  in- 
herited syphilis  are  more  or  less  protected  against  inoculation  with  syph- 
ilitic virus. 

Any  incidental  symptoms  that  occur  during  the  progress  of  either  ac- 
quired or  hereditary  syphilis  must  be  managed  on  general  principles. 
Thus,  impaired  digestion,  constipation,  fever,  sleeplessness,  and  such  con- 
ditions, may  require  laxatives,  astringents,  refrigerants,  or  hypnotics. 

The  local  treatment  of  syphilitic  lesions  is  important,  but  far  less  so 
than  the  general  treatment,  except  in  the  case  of  iritis.  In  iritis  it  is  abso- 
lutely essential  to  drop  immediately  into  the  eye  a  strong  solution  of  atropia 
(about  four  grains  of  atropia  sulphate  to  the  fluidounce  of  water) ;  because, 
if  this  is  delayed,  the  iris  will  become  glued  to  the  anterior  capsule  of  the 
lens,  and  the  permanently  contracted  pupil  be  occluded  by  the  deposit  of 
infiammatory  lymph.  Hence,  wide  dilatation  of  the  pupil  mu.st  be  ob- 
tained at  once,  after  which,  or  indeed  during  the  same  time,  constitutional 
remedies  are  administered. 

]Mucous  patches  and  ulcerations  should  be  touched  with  fused  silver 
nitrate  or  a  solution  of  nitrate  of  mercury  (1  :  10).  Cutaneous  ulcers 
will  heal  more  rapidly  if  slightly  stimulated  with  diluted  ointment  of 
nitrate  of  mercury  (1  :  10),  or  with  some  astringent,  such  as  copper  sul- 


TREATMENT.  83 

phate,  silver  nitrate,  nitrates  of  mercury,  iodoform,  or  chloral.  The  various 
remedial  measures  described  under  ulcers  are  applicable. 

The  falling  of  the  hair,  technically  called  alopecia,  may  require  stimu- 
lating applications  to  the  scalp,  such  as  alcohol,  ointment  of  the  nitrate 
of  mercury,  tincture  of  cantharides,  tannic  acid,  and  ammonia,  suitably 
diluted. 

Lymphatic  glandular  involvement  may  be  benefited  at  times  by  pres- 
sure, absorbent  plasters  and  lotions,  and  by  interstitial  injections  of 
alcohol  or  iodine. 

Periostitis,  which  often  causes  excruciating  pain,  may  be  relieved  by 
blisters,  or  by  subcutaneous  incision  of  the  periosteum,  which  relieves 
tension. 

Other  opei'ations  may,  at  times,  be  required  for  the  removal  of  diseased 
bone  or  irrevocablv  degenerated  members. 


CHAPTER   AT. 

RICKETS   OR   RACHITIS. 

Definition. — Rickets  is  a  diathetic  atfection,  uiul,  therefore,  should 
not  be  described  under  disease  of  bone,  but  in  the  present  connection.  Its 
characteristic  is  an  abnormal  deposition  of  cartilaginous  material,  with 
incomplete  ossification.  The  effects  of  this  constitutional  condition  are 
shown  in  softening  and  distortion  of  bones,  and  in  changes  resembling 
amyloid  degeneration  in  the  liver,  spleen  and  other  organs. 

Pathology. — Rickets  seems  to  depend  upon  maluutrition,  which 
causes  deposition  of  abnormally  large  areas  of  soft,  cartilaginous  tissue 
which  cannot  be  at  once  perfectly  ossified  by  calcific  transformation. 
Hence  the  bone  is  thickened  by  soft,  subperiosteal,  cartilaginous  deposits, 
which  do  not  add  to  its  strength,  because  the  medullary  cavity  is  simul- 
taneously increasing.  The  bones  are,  therefore,  easily  bent  out  of  shape. 
The  epiphyseal  cartilages,  in  a  similar  way,  are  enlarged,  and,  becoming 
imperfectly  ossified,  allow  deformity  in  the  vicinity  of  the  joints.  Marked 
deposition  is  apt  to  occur  about  the  edges  of  the  cranial  and  other  fiat 
bones.  After  a  time  excessive  deposit  of  bone  salts  occurs,  and  sclerosis, 
or  abnormal  hardening,  of  the  bones  takes  i)lace.  The  visceral  changes 
resemble  amyloid  or  waxy  degeneration. 

Causks. — The  etiology  of  rickets  is  unknown.  Heredity,  food  deficient 
in  organic  salts,  and  the  presence  of  lactic  acid  or  phosphorus  in  excessive 
amounts  have  been  named,  but  not  established  as  causative  factors.  Defi- 
ciency in  amount  of  fresh  food  is  an  important  factor  in  its  production. 

Symptoms. — Rickets  is  a  disease  of  childhood,  and  appears  about  the 
.second  or  third  year  of  life.  The  premonitory  symptoms  are  not  distinc- 
tive, and  no  definite  diagnosis  can  be  made  until  the  enlarged  extremities 
of  the  long  bones,  the  nodules  at  the  junction  of  ribs  and  costal  cartilages, 
and  the  bending  of  the  bones  by  muscular  traction  and  the  weight  of  the 
body  in  walking,  point  out  the  rachitic  condition.  The  child  may  be 
restless,  sweat  profusely  about  the  head,  show  digestive  derangement, 
exhibit  irregularity  in  dentition,  and  complain  of  muscular  pain  upon 
moving  or  being  handled.  There  is  often  no  febrile  movement.  The 
liver  and  spleen  are  often  enlarged,  and  the  child  listless,  emaciated  and 
somewhat  sluggish  in  mental  development.  Os.seous  deformities  of  the 
limbs,  anterior  thoracic  region,  spine  and  pelvis  are  commonly  exhibited 
in  tuberous  enlargements  and  curvatures.  Partial  or  complete  fracture 
may  occur.  The  fontanelles  close  slowly,  and  the  occipital  bone  may  be- 
come thinned.  These  symptoms  may  abate,  as  if  convalescence  was  at 
hand,  and  be  followed  by  recurrence  of  symptoms.  It  is  not  usually  a 
fatal  disease,  but  recovery  slowly  supervenes,  accompanied  by  abnormal 
induration  of  the  distorted  skeleton. 

Treatment. — The  treatment  must  consist  of  feeding  with  the  most  nu- 
tritious food,  as  mother's  milk,  cow's  milk,  broths,  etc.,  and  the  adminis- 
tration of  cod-liver  oil  (fgss-ij  three  or  four  times  daily),  syrup  of  iodide 
of  iron  (n^x-xxx),  quinia    (gr.  i-v),  compound    syrup    of  phosphates 


TREATMENT.  85 

(Ti|^x-f3ij),  or  syrup  of  lacto-phosphate  of  lime  (rrLx-fgj).     Fresh  air, 
bathing  and  frictions  are  valuable  adjuvants.  "'"■iil'lsi 

During  the  stage  of  softening,  deformity  of  the  bones  should  be  averted 
by  prohibiting  locomotion,  and  by  the  application  of  splints  or  plaster-of- 
Paris  dressings.  After  convalescence,  slight  curvatures  will  often  be  cor- 
rected by  muscular  action  during  the  growth  of  the  child.  If  the  deformity 
is  great  and  permanent,  osteotomy  may  be  demanded  to  relieve  lameness 
or  to  improve  appearances. 


CHAPTER    VII. 

TUMORS.  ■ 

Definition. — A  tumor,  or  morbid  growth,  is  a  circumscribed  enlarge- 
meut  of  living  tissue,  abnormal  to  the  part  and  having  no  physiological 
function,  which,  in  its  growth,  is  independent  of  the  adjacent  structures, 
and  which  is  not  the  result  of  an  inHammation.  It  is  an  atypical  new 
formation.  Most  cysts  are  not  strictly  tumors.  Condylomata  are  inflam- 
matory formations,  not  tumors. 

Causes. — The  cause  of  all  morbid  growths  is  abnormal  activity  of  the- 
cellular  elements  from  which  they  originate,  but  the  factors  or  primary 
causes  inducing  this  morbid  activity  of  preexisting  cells  are  not  easily 
discoverable. 

It  is  j)robablethat  the  cause  of  tumors  is  local  rather  than  general,  for, 
although  blood  alterations  and  hereditary  conditions  may  influence  their 
progress,  the  development  of  such  morbid  growths  seems  to  depend  on 
peculiarities  of  the  ti.ssue-cells.  These  peculiarities  may  be  due  to  in- 
herited cellular  eccentricity  which  readily  responds  to  any  existing  cause, 
or  to  local  irritation  from  injurious  impressions  or  from  the  immigration 
of  foreign  elements  coming  from  primary  morbid  growths  situated  at  a 
distance.  Many  efforts  have  been  made  to  prove  the  dependence  of 
tumors,  especially  malignant  growths,  upon  microorganisms,  but  thus  far 
unsuccessfully.  The  most  tenable  theory  for  benign  growths  is  that  there 
has  been  left  imbedded  in  the  tissues  a  few  embryonic  cells,  not  em- 
ployed in  the  development  of  the  animal  in  the  prenatal  stage  of  ex- 
istence, which,  in  after-life,  assume  activity  and  develop  into  tumors.  It 
has  been  suggested  that  the  occurrence  of  carcinomas  is  due  to  the  normal 
resistance  of  connective  tissue  being  reduced  until  epithelium,  which  has 
an  active  power  of  growth,  invades  it. 

Pathology. — Tumors  are  always  developed  from  cells  which  have  pre- 
viously existed,  either  at  the  present  seat  of  the  growth,  or  at  some 
distant  spot  from  which  they  have  been  transported  to  the  locality  occu- 
pied by  the  tumor.  The  tumor  in  the  former  case  is  a  primary,  in  the 
latter  a  secondary,  morbid  growth.  The  histological  structure  and  de- 
velopment of  every  tumor  resemble,  in  a  greater  or  less  degree,  some 
normal  or  physiological  tissue — that  is,  all  pathological  formations  belong 
to  some  physiological  type.  The  resemblance  is  not  exact,  however ;  they 
are  atypical.  These  axioms  may  be  cleai'ly  illustrated  by  saying  that  no 
tumor  can  be  formed  from  cloth  or  straw,  but  in  its  construction  and 
growth  must  reseml)le  some  animal  tissue.  The  original  elements  from 
which  tumors  are  developed  are  cells  of  connective  tissue,  of  epithelium, 
of  glands,  of  muscle,  or  of  nerve.  The  morbid  growths  originating  from 
muscle-  and  from  nerve-cells  are  rare,  those  arising  from  epitlielial  and 
glandular  origins  quite  common,  and  those  developed  from  a  connective- 
tissue  basis  exceedingly  frequent. 

A  tumor  whose  structure  is  similar  to  the  part  from  which  it  originated 
or  in  which  it  lies,  is  called  homologous  ;  one  which  differs  from  the  tissue 
that   gave   it  birth,  or  in  which  it  is  situated,  is  termed  heterologous. 


PATHOLOGY.  87 

These  terms  are  somewhat  relative  ;  for  example,  a  cartilaginous  tumor 
growing  from  the  larynx  would  be  homologous,  but  if  appearing  in  the 
testicle  it  would  be  heterologous.  Heterology  is  especially  characteristic 
of  malignant  growths  because  they  spread  into  tissues  different  from  their 
original  site,  and  are  even  transported,  by  the  blood  and  lymph  currents, 
to  distant  parts  of  the  organism,  such  as  the  internal  viscera. 

An  important  point  in  regard  to  the  relation  of  the  new  growth  to  the 
adjacent  tissues  is  the  presence  or  absence  of  infiltration.  If  the  tumor 
blends  with  the  surrounding  parts  so  that  the  microscope  discloses  tumor 
cells  involving  the  muscular  and  cellular  tissue  of  the  neighborhood, 
infiltration  exists  and  the  tumor  is  dijf'use.  This  infiltration  is  very 
common  in  malignant  tumors,  but  may  not  be  apparent  to  the  unaided 
eve.  A  circumscribed  growth  is  one  which  is  definitely  separated  from 
the  adjacent  structures,  which  it  has  pushed  apart  during  it  development. 
It  is  often  isolated  from  them  by  a  capsule  of  condensed  fibrous  tissue. 
Such  growths  may,  during  their  progress,  become  diffuse.  Microscopic 
examination  is  the  only  test  of  the  absence  of  infiltration  even  in  growths 
which  appear  to  be  encapsulated. 

Tumors  occasionally  disappear  by  atrophy  or  absorption,  and  at  times 
reach  a  certain  bulk  and  remain  stationary  ;  but  usually  they  increase  in 
size.  This  increase  frequently  occurs  rapidly  even  though  the  patient  is 
losing  weight.  They  may  undergo  changes,  such  as  fatty  degeneration, 
calcification,  pigmentary,  colloid  and  mucoid  degeneration,  inflammation, 
ulceration,  and  mortification,  in  a  manner  similar  to  tissues  not  patho- 
logical in  their  origin.     Tumors  have  no  nerves. 

The  tendency  which  certain  morbid  growths  have  to  be  reproduced, 
either  at  the  original  site,  after  excision,  or  in  other  regions  by  infiltrating 
or  infecting  the  tissues,  is  designated  malignancy.  Hence,  tumors  are 
malignant  and  non-malignant.  Malignant  tumors,  as  previously  stated, 
are  capable  of  infiltrating  neighboring  tissues  with  their  cells ;  and  by 
this  and  perhaps  other  means  they  influence  such  abnormal  activity  in 
the  part  that  similar  growths  arise  at  the  circumference  of  the  original 
tumor.  Hence,  it  is  not  unusual  to  see  a  neoplasm  surrounded  by  a 
series  of  small  nodules. 

When  the  surgeon  removes  a  malignant  tumor  he  may  leave  tissue 
which  has  recently  been  infiltrated  with  the  tumor  cells,  but  which  appears 
to  be  normal.  These  cells,  either  by  their  own  proliferation  or  by  in- 
fluencing proliferation  in  the  native  cells  of  the  part,  cause  a  similar 
tumor  to  appear  at  the  cicatrix  and  its  vicinity.  The  development  of 
secondary  tumors  from  malignant  growths  may  occur  in  another  way.  The 
lymphatic  circulation  through  the  original  disease  may  carry  cells  of  the 
tumor  to  the  nearest  lymphatic  glands,  where  they  are  arrested,  and,  as  in 
the  former  case,  induce  secondary  growths  similar  to  the  primary.  A 
third  manner  of  inducing  secondary  tumors  is  a  similar  transference  of 
cellular  elements  by  means  of  the  blood  current  passing  through  the 
growth.  These  tumor  cells  are  arrested  by  arteries  or  by  veins  in  some 
distant  capillary  system,  often  the  nearest,  and,  as  in  the  lymphatic  method 
of  infection,  induce  secondary  groAvths. 

Thus,  it  is  evident  that  malignant  tumors  produce  others  like  them- 
selves by  infiltration  and  by  lymph  and  blood  infection.  Other  methods 
may  at  times,  though  rarely,  be  operative.  Tumors  often  show  a  decided 
preference  for  one  or  other  of  these  methods  of  reproduction.  The  sec- 
ondary growths  may,  in  the  same  way,  act  as  parents  and  produce  a 
progeny  with  characteristics  similar  to  their  own.     This  transference  of 


88  TUMORS. 

cellular  elements  explains  the  circumstance  that   maliLriiant   tumors  are 
frequently  heterologous. 

It  must  not  he  forgotten,  as  it  often  is,  that  multiple  tumors,  even  when 
malignant,  may  not  be  secondary  to  another,  but  may  be  synchronous  or 
due  to  the  same  original  cause. 

Fron)  the  description  given  of  the  processes  by  which  reproduction  of 
malignant  growths  is  accomi)lished,  it  is  evident  that  the  most  malignant 
growths  would  be  those  containing  the  greatest  number  of  cells,  the  most 
juice,  and  the  greatest  abundance  of  lymphatic  vessels  and  bloodvessels. 
The  reverse  of  this  picture  would  give  non-malignant  or  benign  tumors, 
which,  as  they  approach  the  characteristics  of  the  other  group,  become 
more  or  less  malignant  in  nature.  In  fact,  there  is  no  absolute  line  drawn 
by  nature  dividing  the  malignant  from  the  non-malignant;  although  it  is 
admitted  that  tumors  with  one  histological  structure  are  usually  malig- 
nant, and  others  usually  benign,  either  class  may  occasionally  assume  the 
clinical  nature  of  the  other. 

Cl.\ssikk;ation. — Tumors  are  chissified  according  to  their  histological 
structure,  which,  as  I  have  previously  stated,  always  resembles,  in  a 
greater  or  less  degree,  some  physiological  tissue  either  of  adult  or  foetal 
life.  The  imperfect  knowledge  that  we  ])ossess  of  the  development  of 
many  tissues,  and  the  varying  degrees  of  relative  importance  attaciied  by 
pathologists  to  the  microscopic  elements  seen  in  the  growth,  prevent  a 
universal  acceptation  of  a  single  classification.  I  have  accepted  that  given 
by  Green  {Pathology  and  Morbid  Anaiomy),  which  is  convenient  for 
reference,  and  more  familiar  to  the  American  profession,  perhai)s,  than 
any  other. 

Classification  of  Tumors. 

I.   Tumors  u-hnse  rjeneral  structure  or  type  resembles  one  of  the  modijications  of  fully 
developed  connectice  tissue. 
Special  types : 

1.  Fil)rous  tissue.  Fibrous  tumor.  Fibroma. 

2.  Adipose  tissue.  Fatty  tumor.  Lipoma. 

3.  Cartilage.  Cartilaginous  tumor.  Chondroma. 

4.  Bone.  Bony  tumor.  Osteoma. 

5.  Mucous  tissue.  Mucous  tumor.  My.xoma. 
(not  mucous  membrane.) 

6.  Lymphoid  tissue.  Lymphatic  tumor.  Lymphoma. 

II.   Tumors  u-hose  general  structure  or  type  resembles  that  of  one  of  the  higher  or  more 
complex  tissues  than  fully  developed  connective  tissue. 
Special  types : 

1.  Muscular  tissue.  Muscular  tumor.  Myoma. 

2.  Nervous  tissue.  Nerve  tumor.  Neuroma. 

3.  Bloodvessels.  Vascular  tumor.  Angioma. 

4.  Lymphatic  vessels.  Lymphatic  vessel  tumor.  Lymphangioma. 

III.   Tumors  whose  general  structure  or  type  is  that  of  the  undeveloped  connective  tissue 

of  the  embryo. 
Sarcomas. 

These  are  luimed  according  to  the  shape  and  size  of  the  predominant  constituent  cell 
(round-cell,  giant-cell,  etc.) ;  according  to  the  character  of  the  stroma  (osteo-sarcoma, 
myxo-sarcoma) ;  or  according  to  the  retrogressive  changes  that  occur  in  the  tumor 
(melano-sarcoma,  calcifying  sarcoma). 

IV.   Tumors  whose  general  type  is  that  of  epithelial  tissue. 

1.  Papillae  of  skin  or  mucous  membrane.  Papilloma. 

r  Adenoma. 

2.  Glands.  ]  Carcinoma. 


TREATMENT,  89 

Under  eareinomas,  then,  are  : 

1.  Acinous  carcinoma. 

a.  Scirrhoma,  or  chronic  carcinoma. 

b.  EnceiDhaloma,  or  acute  carcinoma. 

2.  Epithelial  carcinoma. 

a.  Squamous  epithelioma. 

h.  Columnar-cell  epithelioma  ;  often  called  adenoid  carcinoma. 
•3.  Colloid  carcinoma. 

V.   Congenital  mixed  tumors  or  teratoniata. 

Tumors  due  to  inclusion  and  imperfect  development  of  one  foetus  within  another,  or 
abnormal  development  of  a  single  fa3tus.     Dermoid  cj^sts  belong  in  this  division. 

Clinical  History. — Tumors  present  innumerable  varieties  as  to  size, 
form,  consistence,  number,  situation,  and  other  physical  characteristics. 
These  clinical  attributes  have  much  to  do  with  the  symptoms  of  the 
growth  ;  for  example,  a  small  tumor  passing  on  a  nerve-trunk  will  pro- 
duce more  pain  than  a  large  one  in  another  locality ;  one  overlying  an 
artery  will  receive  transmitted  pulsation,  another  pressing  upon  a  vein 
will  cause  mechanical  dropsy.  Certain  tumors,  especially  the  carcinomas, 
have  a  tendency  to  ulcerate  and  become  the  seat  of  hemorrhage. 

Those  growths  whose  clinical  history  is  conspicuous  because  of  their 
infiltration  of  adjacent  structures,  recurrence  after  removal,  and  i-epro- 
duction  in  distant  regions  of  the  body,  are  called  malignant.  The  car- 
cinomas and  many  of  the  sarcomas  usually  present  this  feature  of  malig- 
nancy ;  the  other  groups,  as  a  rule,  are  not  malignant.  There  are,  how- 
ever, occasional  exceptions,  for  sarcomas  and  even  carcinomas  sometimes 
act  as  non-malignant  growths,  while  others,  ordinarily  benign,  at  times 
assume  a  decidedly  malignant  expression. 

Causes  of  Death. — Death  may  occur  from  morbid  growths  on  account 
of  hemorrhage ;  asthenia  due  to  excessive  discharge ;  nervous  irritation ; 
mechanical  interference  with  nutrition  ;  asphyxia;  and  profound  involve- 
ment of  the  nervous  centres.  Many  tumors  have  no  tendency  to  impair 
the  general  health.     This  is  especially  true  of  the  non-malignant  growths. 

Treatment. — The  treatment  of  tumors  depends  on  their  character. 
Malignant  growths,  and  those  suspected  to  have  that  character,  should, 
as  a  rule,  be  removed  by  operation  as  early  as  possible.  The  excision 
should  extend  far  beyond  the  apparent  outlines  of  the  tumor,  because 
infiltration  has  probably  taken  .place,  though  not  appreciable  to  the  eye 
of  the  surgeon.  Benign  growths  may  be  allowed  to  remain  if  they  neither 
interfere  with  the  functions  of  the  part  nor  cause  indirect  deterioration  of 
health.  If  they  show  indications  of  probable  future  injurious  influences 
they  should  be  removed  while  still  small,  provided  the  excision  can  be 
done  without  great  risk.  If  the  tumor  is  more  serious  in  its  present  or 
future  aspects  than  the  operation,  operation  is  justifiable;  but  when  the 
operation  is  more  serious  than  the  probable  effects  of  the  undisturbed 
tumor,  operation  is  not  j  ustifiable. 

In  excising  tumors  involving  deep  structures  and  having  firm  attach- 
ments, the  operator  should  endeavor  at  once  to  become  master  of  the  situ- 
ation by  coping  at  first  with  the  most  troublesome  portions  of  the 
growth.  It  is  unsurgical  to  spend  time  freeing  superficial  adhesions  and 
tying  vessels  which  will  in  a  moment  be  cut  again  at  a  lower  level.  It 
is  far  better  to  work  under  the  deeper  portions  of  the  tumor,  as  soon  as  a 
free  cutaneous  incision  has  been  made,  and  thus  control  the  primary 
sources  of  hemorrhage.     This  method  of  operating  enables  the  surgeon 


90 


T  U  .M  O  R  S  . 


to  approcinte  more  accurately  the  character  of  operative  procedure  de- 
nuiuded  for  the  extirpation  of  the  growth. 

When  tumors  cannot  he  removed,  relief  of  pain  may  often  be  obtained 
by  open  or  subcutaneous;  division  of  the  fascias  bindintr  them  down,  or 
by  excision  or  stretching  of  nerve-trunks. 

Excision  of  insignificant  tumors  is  often  proper  because  of  the  unsight- 
liness  produced  by  them,  and  the  mental  perturbation  induced  by  their 
existence. 

SpECiAT,  Tumors. 

I.  Tumom  ivhoxe  general  drudure  or  type  resembles  one  of  the  modifica- 
tlous  of  fully  developed  connective  tissue. — Growths  of  this  class  are  non- 
malignant,  for  when  any  of  them,  such  as  fibroma,  enchondroma,  A'ld 
osteoma,  occasionally  assume  a  malignant  expression,  it  is  found  on  micro- 
scopic examination  that  they  are  wholly,  or  in  part,  sarcomatous.  This 
accords  with  the  well-known  fact  that  a  tumor  may  present  in  its  different 
parts  the  structure  of  more  than  one  variety  of  morbid  growth. 

FiBROMAs,  OR  Fibrous  Tumors. — These  growths  may  be  divided 
into  soft  and  hard  fibromas.  The  former  grow  somewhat  rapidly,  are 
smooth,  rather  soft  and  elastic,  and  often  pedunculated  ;  they  are  at  times 
diffuse,  though  often  circumscribed  and  encapsulated,  and  give  rise  to  no 
pain  or  inconvenience  except  from  their  weight.  On  section  they  occa- 
sionally exude  a  large  amount  of  serous  fluid.  The  hard  fibrous  tumors 
are  of  slow  growth,  are  smooth,  very  firm,  usually  single,  generally 
movable  unless  having  bony  attachments,  painless,  and  encapsulated. 
Fibromas,  as  a  rule,  have  few   vessels,  but   they  are  occasionally  very 


Fig.  10. 


Fig.  11. 


Section  of  fibroma,  showing  tj'pi- 
cal  fibrous  character.  In  this  portion 
of  tumor  no  cells  were  seen.  X  220. 
(Holmes.) 


Section  of  lipoma,  showing  nucleated  oil- 
cells  andsome  crystals  of  margarin.  X  220. 
(Holmes.) 


vascular,  and  then,  as  the  fibrous  surroundings  of  the  vessels  prevent  re- 
traction and  contraction,  severe  hemorrhage  may  follow  their  removal. 
Fibrous  tumors  originate  from  the  fibrous  tissue  of  the  skin,  connective 
tissue,  subcutaneous   and   submucous   tissue,    periosteum,  fascias,  nerve- 


CHONDROMAS,    OK    CARTILAGINOUS    TUMORS.  91 

sheaths,  and  other  structures ;  and  are  found  in  many  situations.  They 
constitute  one  form  of  epulis,  a  variety  of  naso-pharyngeal  polypus,  and 
the  so-called  false  neuroma.  The  last  is  a  fibroma  developed  from  the 
connective  tissue  in  the  nerve  and  having  nerve- fibres  spread  over  its  sur- 
face. Such  tumors  are  often  multiple,  and  are  painless.  The  painful 
subcutaneous  tubercle  is  considered  b}^  some  a  fibroma  which  has  no 
demonstrated  connection  with  nerve-fibres ;  others  think  it  is  a  true 
neuroma,  or  nerve  tumor.  Uterine  fibroid  tumors  are  usually  myomas. 
Fibrous  tumors  may  undergo  softening,  calcification,  ulceration,  and  cystic 
degeneration. 

Microscopically,  fibroid  tumors  consist  of  fibrous  tissue  more  or  less 
compactly  interlaced,  associated  with  a  few  fusiform  or  star-like  cells 
which  are  often  indistinct.  Rapidly  developed  fibromas  usually  present 
a  greater  proportional  abundance  of  cells,  and  are  soft  in  consistence. 

Some  fibromas  closely  approach  the  sarcomas  in  their  microscopical  and 
clinical  features. 

The  treatment  of  ordinary  fibrous  tumors  consists  in  non-interference, 
unless  their  bulk  or  situation. demands  removal.  They  are  non-malig- 
nant. 

Lipomas,  or  Fatty  Tumors.  —  A  circumscribed  accumulation  of 
adipose  tissue  is  called  a  fatty  tumor.  They  occur  anywhere,  though 
especially  about  the  back  and  shoulders.  I  once  saw^  one  removed  from 
the  palmar  aspect  of  the  hand ;  I  think  it  was  in  the  tissues  of  the  ball 
of  the  thumb.  Such  tumors  are  of  slow  growth,  though  they  may  reach  a 
very  large  size ;  are  soft,  doughy,  and  sometimes  slightly  fluctuating. 
Often  they  are  distinctly  lobulated  and  frequently  cause  a  dimpling  of  the 
integument  at  the  situation  of  the  fibrous  septa  attaching  the  skin  to  the 
deep  fascia;  they  may  become  pendulous,  and  even  change  their  position 
under  the  skin  by  the  action  of  gravity ;  they  are  painless  and  seldom 
undergo  degeneration,  softening,  or  ulceration. 

They  consist  of  indistinctly  nucleated  cells  distended  with  fluid  fat  and 
connected  by  a  variable  amount  of  connective  tissue.  As  these  cells  in- 
crease in  number  by  jDroliferation  they  are  filled  with  fat,  and  thus  the 
growth  acquires  bulk.  The  mass  is  usually  surrounded  by  a  capsule  of 
condensed  connective  tissue.  It  is  their  localization  that  distinguishes 
fatty  tumors  from  ordinary  obesity.  If  lipomas  require  treatment  they 
are  to  be  removed  by  means  of  a  free  incision  through  the  skin,  which 
enables  the  surgeon  to  turn  them  out  of  the  capsule  with  great  ease.  No 
portion  of  the  tumor  should  be  left  behind  to  reproduce  the  growth. 

Chondromas,  or  Cartilaginous  Tumors. — These  growths  are  found 
especially  among  young  patients,  and  are  frequently  connected  Avith  the 
bones  of  the  fingers.  They  are  rarely  developed  from  preexisting  carti- 
lage. They  occur  also  in  glands,  such  as  the  parotid,  testicle  and  mamma, 
and  occasionally  in  the  lungs.  When  connected  with  the  phalanges  of 
the  hands  or  feet  they  are  usually  multiple,  otherwise  they  are  single. 
Cartilaginous  tumors  are  smooth,  hard  and  elastic,  and  often  lobulated 
masses ;  of  slow  development,  usually  surrounded  by  a  capsule,  and  non- 
malignant. 

Occasionally,  however,  they  are  much  softer  than  usual,  grow  rapidly, 
have  no  capsule,  recur  after  removal,  infect  distant  tissues  by  cell  trans- 
ferrence,  and  present  decidedly  malignant  characteristics.  These  tumors 
usually  show,  especially  at  their  circumference,  sarcomatous  structure  in- 
filtrating adjacent  tissues;  hence  they  are  not  to  be  considered  true 
chondromas. 


92 


TUMORS. 


There  is  a  form  of  tumor  called  osteo-chondroiiia,  which  consists  of 
bone  associated  with  cartilage  and  originates  under  the  periosteum  near 
the  articular  extremities  of  the  long  bones.  They  may  become  trans- 
formed into  true  osseous  tissue. 

Fig   12. 


Multiple  euchondroma  of  fingers. 


Chondromas,  or  enchondromas,  as  they  are  also  called,  are  in  structure 
almost   identical   with    the  varieties   of  cartilage,  and   yet   they  rarely 

Fig.  14. 


Fig.  l.'^. 


Hyaline  enchondroma,  showing  cells 
with  nuclear  contents  lyintc  in  a  hyaline 
matrix.     X  200.     (Grkek.) 


Section  of  an  exostosis  covered  with  a 
laverof  cartilage.  The  cartilage  is  seen  at 
top  of  figure.     X  220.     (Holmes.) 


originate  from  cartilage.     They  exhibit  cells  with  nuclear  and  granular 
contents  enclosed  in  a  matrix"  which  varies  from  a  hyaline  to  a  fibrous 


MYXOMAS,    OR    MUCOUS    TISSUE     TUMORS.  93 

or  mucoid  character.  They  are  usually  developed  from  the  bone  or  from 
connective  tissue,  and  not  from  cartilage  ;  very  occasionally  they  originate 
from  costal,  laryngeal,  and  other  cartilages  in  the  same  manner  as  exos- 
toses grow  from  bone.  It  has  been  proposed  to  call  these  overgrowths 
enchondroses. 

Changes  of  a  calcareous  or  ossific  character  quite  often  affect  cartilagi- 
nous tumors.  Sometimes  portions  soften  in  the  interior  of  the  growth 
and  cause  au  appearance  resembling  cystic  degeneration.  If  the  size  of 
enchondromas  does  not  render  them  objectionable  or  dangerous,  they  may 
be  left  undisturbed.  Under  other  circumstances  excision  of  the  growth 
or  amputation  of  the  affected  bone  is  demanded.  In  the  sarcomatous 
enchondromas  prompt  operation  is  probably  the  best  treatment. 

Osteomas,  or  Bony  Tumors.- — These  growths,  which  must  be  distin- 
guished from  calcareous  degeneration  of  tissue,  are  hard,  painless,  of  slow 
development,  and  frequently  immovable  because  of  their  firm  attach- 
ment to  bone.  They  do  not  acquire  a  great  bulk,  but  may  be  multiple. 
Falls  may  cause  fracture  of  such  tumors.  Inflammation  of  periosteum 
and  bone  will  frequently  give  rise  to  osseous  masses,  as  is  seen  in  long- 
standing periostitis  and  when  callus  is  tbrmed  after  fractures.  These  are 
not  usually  regarded  as  true  tumors,  but  the  line  between  them  and  other 
bony  growths  is  not  very  definite.  Bony  segments  are  occasionally 
formed  in  fibroid  and  cartilaginous  tumors,  because  of  ossific  deo^enera- 
tion  ;  and  at  times  we  have  sarcomas  associated  with  bony  masses.  These 
last  may  show  signs  of  malignancy,  and  hence  must  be  distinguished  from 
true  osteomas,  which  are  benign.  Irregular  masses  of  spongy  bone  are 
often  ossified  chondromas. 

On  section  osteomas  resemble  bone,  showing  lacunae.  Haversian  canals, 
and  canaliculi.  Some  consist  of  cancellated  or  spongy  bone  surrounded 
by  a  thin  layer  of  compact  bony  tissue,  others  are  much  more  compact ; 
while  still  others'  are  so  dense  that  they  show  no  spongy  structure,  and 
are  hence  called  ivory-like  osteomas. 

Bony  tumors  may  originate  from  bone  or  its  accessories  (cartilage  and 
periosteum),  when  they  are  denominated  exostoses,  except  when  they  pro- 
ject into  the  medullary  cavity  and  are  called  enostoses.  The  projections 
of  bony  tissue  found  associated  with  diseased  joints  and  inflamed  bones, 
usually  called  osteophytes,  are  not  tumors,  but  inflammatory  formations. 
The  former  are  frequent  upon  the  interior  or  exterior  of  the  skull,  the 
jaws,  great  toe,  humerus,  and  femur;  the  latter  about  diseased  joints,  mus- 
cles, and  other  structures  undergoing  inflammatory  process.  Osteomas 
occasionally  arise  from  the  medulla  of  bone.  Bony  tumors  are  non- 
malignant,  but  may  require  removal  because  of  deformity,  interference 
with  motion,  pain,  or  ulceration  of  the  overlying  integument.  Excision  by 
bone-cutting  forceps  or  saws,  or  grinding  away  with  the  burr  of  the  surgical 
engine  is  the  proper  method  of  accomplishing  removal.  Subcutaneous 
sawing  or  drilling  followed  by  fracture  may  be  valuable  by  affording 
relief  of  symptoms  without  entire  excision. 

Myxomas,  or  Mucous  Tissue  Tumors. — The  most  familiar  growth 
of  this  class  is  the  mucous  tumor  or  polypus  found  in  the  nasal  cavities. 
Myxomas  are  soft,  often  fluctuating,  smooth  or  somewhat  lobulated,  pain- 
less tumors,  of  slow  growth,  and  surrounded  by  a  thin  capsule.  On  sec- 
tion they  are  yellowish-white  or  pinkish  in  color,  and  exude  an  abundant 
glairy  fluid,  which  examination  shows  to  be  mucus.  The  gelatinous  con- 
sistence and  intercellular  mucous  fluid  are  the  physical  characteristics  of 
the  growth,   which   consists  of  mucous  tissue,  such   as  is  found  in  the 


94  TUMORS. 

vitreous  body  of  the  eye  and  in  the  umbilical  cord,  ^[ucous  ti.ssue. 
which  must  not  be  confounded  with  mucous  membrane,  is  a  form  of  con- 
nective tissue  which  is  translucent  and  possesses  between  its  cells  a  Huid 
containing  mucin.  This  resembles  very  much  the  connective  tissue  of 
the  embryo,  and,  therefore,  some  authorities  class  myxomas  with 
sarcomas. 

j\Iucous  tumors  are  always  developed  from  some  connective  tissue,  such 
as  adipose  tissue,  bone  marrow,  or  the  connective  tissue  of  the  nervous 
structures  and  other  organs.  They  may  exist  in  combination  with  fatty, 
cartilaginous,  sarcomatous,  and  other  growths,  and  may  undergo  cystic 
change.  On  the  other  hand,  various  neoplasms  may  present  a  mucoid 
degeneration  in  spots  which  gives  them  the  semblance  of  myxoma.  Some 
tumors  called  colloid  carcinomas  are  myxomas. 

The  microscopical  examination  discloses  oval,  stellate,  and  spindle- 
shaped  cells,  which  are  generally  nucleated  and  often  possess  elongated 
projections  which  mutually  interlace.  The  intercellular  substance  is 
more  or  less  hyaline,  and  is  homogeneous.  It  is  this  that  gives  the  mucous 
tumors  their  jelly-like  nature  and  furnishes  the  mucous  fluid,  so  charac- 
teristic of  them. 

Myxomas,  if  not  associated  with  sarcoma,  are  benign  ;  and  if  entirely 
removed,  seldom,  if  ever,  recur.  Where  there  is  a  group  of  pendulous 
myxomas,  as  occurs  in  the  nose,  the  removal  of  a  large  one  may,  by  re- 
lieving pressure,  allow  smaller  ones  to  increase,  and  thus  reproduce  the 
old  symptoms ;  but  this  is  not  a  recurrence  of  the  original  growth. 


Fig.  16. 


?T4^^^a^5^£%=^^ 


Section  of  niyxonia,  sliowiiii;  cells  and  Section    oi'   a  liard   Ivniiihoina,  showing 

interlacement   of  prolongations.     X    20(1.         thick     network     and      few     small      cells. 
(Green.)  X  200.     (Green.) 

Lymphomas,  or  Lymphatic  Tissue  Tumors. — These  tumors  are 
composed  of  lymphoid  tissue  similar  to  that  which  is  found  in  lympliatie 
glands,  Malpighian  corpuscles  of  the  spleen,  Peyer's  patches  and  solitary 
intestinal  glands,  the  tonsils,  thymus,  pleura,  marrow  of  bones,  etc.  They 
occur  most  frequently  in  adolescents  or  young  adults  ;  if  of  rapid  develop- 
ment they  are  soft  and  often  become  very  large,  while  if  of  slower 
growth  they  are  hard  and  seldom  attain  any  considerable  size.  Lymphomas 
may  be  found  in  almost  any  situation  because,  as  is  now  known,  lymphatic 
tissue  exists  physiologically  in  many  localities  formerly  considered  desti- 
tute of  this  structure.  The  usual  original  site,  however,  is  the  lymphatic 
glands  of  the  neck,  axilla,  groin,  thorax,  or  abdomen,  whence  the  growth 
may  extend  by  infiltration  to  other   structures.     The  ordinary  inflam- 


MYOMASj    OR    MUSCULAR    TUMORS.  95 

matory  enlargement  of  lymphatic  glands  gives  the  same  microscopical 
appearance,  and  such  swellings  may  be  considered  lymphomas  if  they  con- 
tinue to  increase  in  size,  and  eyen  when  they  merely  persist  without 
diminution  of  bulk. 

Lymphatic  tumors  may  be  lobulated  because  of  successive  involve- 
ments of  a  group  or  chain  of  glands ;  they  are  usually  painless  and  do 
not  tend  to  suppuration  or  degeneratiye  changes. 

The  microscope  reveals  a  network  of  fibrils  containing  in  its  small 
meshes  lymph  corpuscles  which  are  identical  with  white  blood-cells. 

These  cells  sometimes  show  one  or  more  nuclei,  and  sometimes  are 
granular  with  no  visible  nucleus.  At  the  points  where  the  fibrils  of  the 
network  or  stroma  cross,  nuclei  are  occasionally  seen.  In  rapidly  developed 
lymphomas  the  cells  are  abundant  and  large  and  the  stroma  not  very 
marked.  These  are  the  softer  in  consistence,  and  allow  considerable 
milky  juice  to  be  scraped  from  a  cut  surface.  When  the  tumor  has 
grown  slowly  the  network  or  reticulum  is  found  to  be  well-developed  and 
the  cells  small  and  relatively  few  in  number.  These  are  the  hard  variety 
of  lymphatic  tumors. 

Lymphomas  are,  as  a  rule,  non-malignant,  but  those  growths  which  are 
of  rapid  growth  aijd  richly  endowed  with  cell  elements  sometimes  infil- 
trate adjacent  tissues  and  exhibit  a  malignant  tendency.  They  are  allied 
to  the  sarcomas.  Lymphomas  do  not  show  a  tendency  to  caseation  or 
softening  as  do  tuberculous  lymphatic  glands. 

Multiple  lymphomas  constitute  an  essential  clinical  feature  of  Hodg- 
kin's  disease,  which  is  a  j^eculiar  affection  accompanied  by  intense 
ansemia.  In  leuksemia  also  we  have  lymphatic  growths  among  the  patho- 
logical changes  present,  but  in  this  disease  there  is  an  increase  of  the 
white  and  a  diminution  of  the  red  blood-cells,  which  conditions  do  not 
pertain  to  Hodgkin's  disease. 

The  removal  of  lymphatic  tumors  may  be  undertaken  if  the  growths 
are  accessible  and  the  patient  in  fair  health.  When  the  blood  alterations 
associated  with  the  existence  of  the  tumors  are  evidently  profound,  as  in 
Hodgkin's  disease  and  leukaemia,  no  operation  would  be  advisable  or 
justifiable. 

II.  Tamors  tohose  general  structure  or  type  resembles  that  of  one  of  the 
higher  or  more  complex  tissues  than  fully  developed  connective  tissue. 

Myomas,  or  muscular  TUMORS,  are  growths  consisting  of  non-striated 
muscular  fibres  usually  combined  with  more  or  less  connective  tissue. 
Very  rarely  muscular  tumors  are  formed  of  striated  muscular  tissue 
(rhabdo-myomas)  :  these  have  been  usually,  if  not  always,  congenital 
tumors.  Myomas  are  of  slow  growth  and  are  usually  circumscribed  by 
a  sort  of  capsule,  though  at  times  they  are  not  distinctly  bounded ;  not 
infrequently  they  become  pedunculated.  They  possess  considerable  firm- 
ness and  solidity,  are  often  multiple,  and  are  benign.  Their  most  common 
location  is  in  the  uterus,  prostate  gland,  and  digestive  tube;  hence,  they 
show  the  characteristics  of  involuntary  muscular  tissue.  From  the 
abundance  of  connective  tissue  found  associated  with  the  bundles  of 
muscular  fibres,  especially  in  long-standing  tumors,  these  growths,  when  in 
the  uterus,  are  often  termed  uterine  fibroids  or  fibi'o-myomas.  Myomas 
may  undergo  calcareous  and  cystic  degeneration. 

Under  the  microscope  ai-e  seen  long  fusiform  cells  of  involuntary 
muscle,  with  their  characteristic  rod-like  nuclei,  arranged  in  bundles  or 
irregularly  disseminated  through  the  tumor.  There  is  seen  also,  except 
in  some  recent  tumors,  a  good  deal  of  fibrous  tissue.     Myomas  are  inno- 


96 


TUMORS. 


cent,  but  should  be  removed  if  it  ir;  possible  to  do  so,  when  their  location  or 
their  production  of  uterine  hemorrhage  demands  operative  relief.  When 
such  uterine  tumors  are  develojied  near  the  lining  mucous  membrane, 
especially  if  pedunculated,  they  may  be  removed  by  forceps  or  6cra.seur. 
They  are  occasionally  expelled  by  inducing  uterine  contraction  with  ergot. 
It  may  be  necessary  and  advisable  to  remove  the  entire  uterus  by 
abdominal  incision  when  such  growths  cannot  be  enucleated  from  the  ab- 
dominal surface  of  the  womb. 

Neuromas,  ok  Nekvous  Tissue  Tumors. — All  tumors  connected 
with  nerve-trunks  are  not  neuromas,  for  they  maybe  Hbromas,  myxomas, 
etc.;  nor  are  nervous  tumors  necessarily  painful  tumors,  as  might  be  sup- 
posed by  some  readers.  A  neuroma  is  a  rare  form  of  growth  and  consists 
principally  of  ordinary  white  or  inedullated  nerve-fibres.  Gray  nerve- 
tissue  may  be  found  in  neuromas,  but  it  is  exceptional. 

Such  tumors  are  small,  slow  of  growth,  sometimes  multiple,  jjcrhaps 
jjuinful,  and  always  develop  in  the  course  or  at  the  end  of  a  cranial  or 
spinal  nerve.  A  not  infrequent  situation  is  the  end  of  a  nerve-branch 
that  has  been  divided  in  a  previous  amputation  ;  here  they  may  be  com- 
pressed in  the  cicatrix  and  give  rise  to  much  pain.  The  so-called  painful 
subcutaneous  tubercle  is  a  fibroma,  not  a  neuroma. 

Under  the  microscope  nerve  structure  with  some  connective  tissue  is 
seen.  Xervous  tissue  tumors  are  never  malignant,  but  may  require  excision 
when  painful. 

AxGioMAS,  OK  Vascular  Tumors. — Tumors  consisting  of  newly- 
developed  vessels,  bound  together  by  cellular  tissue,  are  angiomas;  hence 
dilatations  of  existing  vessels,  such  as  are  present  in  varicose  veins  and 
varicose  arteries,  often  called  cirsoid  aneurisms  and  aneurisms  by  anasto- 
mosis, are  not  properly  termed  angiomas.  - 

Simple  angiomas  consist  of  structures  resembling  normal  vessels  with 
unusual  tortuosity  and  may  have  a  predominance  of  venules  or  arterioles. 
The  color  of  the  growth  varies  on  this  account  from  pink  to  dark-red  or 

purple.     Such  tumors  are  apt  to  be 
Fig.  17.  congenital    and    small;    and,   some- 

'^>  times,    present   no  elevation  of  the 

skin,  being  mere  stains.  They  con- 
stitute the  well  known  na^vus  niater- 
nus  or  mother's  mark. 

Cavernous  angiomas  are  tumors 
which  are  made  up  of  erectile  tissue. 
This  consists  of  a  series  of  chambers, 
lined  with  endothelium  and  filled 
with  venous  blood,  which  circulates 
freely  through  these  mutually  con- 
nected spaces.  The  walls  of  the 
chambers  are  fibrous  septa.  The 
structure  is  similar  to  that  of  the 
cavernous  portion  of  the  penis,  and 
gives  such  tumors  an  erectile  char- 
acter, which  is  often  accompanied 
by  distinct  pulsation. 

Cavernous   angiomas  are   usually 

of  a  blue  tint;  vary  in  size  according 

to  the  amount  of  engorgement,  though  ordinarily  giving  rise  to  distinct 

prominence;  often  grow  rapidly,  especially  in  cutaneous  and  loo.se  areolar 


Cavernous  angioma  of  nioiitli  and  clieek 
in  a  child  of  two  and  a  half  years. 


MYOMAS,    OR    MUSCULAR    TUMORS.  97 

tissue;  and  are  not  markedly  congenital.     Injury  to  cavernous  angioma 
is  followed  by  profuse  hemorrhage. 

Lymphatic  vessels  sometimes  communicate  with  cavernous  spaces, 
similar  to  those  described  as  occurring  in  cavernous  angiomas.  A  tumor 
is  then  formed,  which  is  called  a  cavernous  lymphangioma.  There  is 
also  a  form  of  lymphangioma  which  consists  simply  of  a  mass  of  lym- 
phatic vessels ;  being,  in  fact,  similar  to  the  simple  angioma  above  de- 
scribed. 

The  treatment  of  vascular  tumors  Avill  be  described  in  the  section  de- 
voted to  diseases  of  the  bloodvessels  more  fully  perhaps  than  here.  They 
are  non-malignant ;  but  some  forms  may  tend  to  produce  death  by  hem- 
orrhage, occurring  from  slight  abrasion  of  their  surface  or  from  ulcer- 
ation. 

No  treatment  is  demanded  for  angiomas  ^Yhich  do  not  increase,  nor 
threaten  life  from  ulceration  and  hemorrhage,  unless  the  deformity  or 
personal  disfigurement  is  a  source  of  anxiety.  Sometimes,  though  rarely, 
they  atrophy  spontaneously.  Capillary  dilatations  situated  solely  in  the 
skin,  causing  the  pink  discolorations  often  called  port-wine  marks,  may 
be  removed  by  puncturing  wath  red-hot  needles  or  electrolytic  needles,  or 
by  applying  caustics,  such  as  chromic  acid.  These  marks  are  often  unac- 
companied by  any  increase  in  the  bulk  of  the  part.  Under  such  circum- 
stances they  can  scarcely  be  called,  with  propriety,  vascular  tumors. 
Some  of  these  superficial  congenital  discolorations  gradually  increase  in 
thickness,  and  become  true  angiomas. 

Purely  subcutaneous  angiomas  present  themselves  as  spongy,  doughy 
tumors,  from  which  pressure  expels  the  blood  more  or  less  completely, 
leaving  in  the  fingers  a  much  smaller  tumor.  If  largely  composed  of 
arteries,  they  have  a  pulsatile  character,  and  a  murmur  which  causes 
them  to  resemble  aneurisms.  The  pulsation,  however,  partakes  rather  of 
the  character  of  a  thrill  than  of  a  beat  synchronous  wath  the  heart  move- 
ments. The  spongy  consistence  and  the  fact  that  pressure  on  one  artery 
does  not  obliterate  the  thrill  and  murmur  aid  in  diagnosis.  The  angioma, 
moreover,  is,  probably,  not  located  in  the  course  of  an  artery.  Angiomas 
in  bone  resemble  malignant  tumors. 

Vascular  tumors,  which  involve  both  the  skin  and  the  subcutaneous 
tissue,  are  easily  diagnosticated.  They  may  cause  great  deformity,  and 
even  erosion  or  displacement  of  the  bones.  The  treatment  of  the  subcu- 
taneous angioma  and  of  this  last  form  is  identical,  except  that  in  the 
former  case  the  skin  should  be  lifted  up  in  one  or  more  flaps  and  preserved 
if  excision  or  strangulation  of  the  tumor  is  practised. 

The  three  methods  of  dealing  with  these  tumors,  which  are  sometimes 
called  thick  nsevi,  are  injection  of  coagulating  liquids,  strangulation  and 
excision.  I  believe  the  last  to  be  the  best  in  nearly  all  instances.  Injec- 
tion is  accomplished  by  introducing  the  needle  of  a  hypodermatic  syringe 
into  the  centre  of  the  growth,  and  after  tearing  the  tissue  somewhat  by 
to-and-fro  movements  of  the  needle-point,  forcing  twenty  minims  of  the 
liquid  into  the  meshes  of  the  tumor  by  means  of  the  piston.  Tincture  of 
the  chloride  of  iron,  or  a  w'atery  solution  of  similar  strength,  or  chloride 
of  zinc  (gr.  x  to  the  fluidounce  of  water),  are  proper  agents  to  employ,  if 
this  treatment  is  adopted.  There  is,  however,  danger  of  causing  disfigur- 
ing scars  from  sloughing  following  the  induction  of  too  high  a  grade  of 
inflammation.  Fatal  embolism  has  also  occurred  from  fragments  of  the 
coagulated  blood  being  washed  into  the  general  circulation.  This  may 
be  guarded  against  to  some  extent,  by  previously  encircling  the  tumor 

7   "      . 


98 


TUMORS. 


with  a  lijiature,  or  with  a  ring  of  metal  or  rubber,  which  is  kept  in  place 
for  a  few  minutes  after  the  injection.  The  temjwrary  ligature  may  be 
adjusted  and  kept  from  slipping,  with  more  ease,  by  transfixing  the  tissue 
under  the  base  of  the  tumor  with  a  pin,  under  the  ends  of  which  the  liga- 
ture is  passed. 

Strangulation  maybe  accomplished  in  three  ways :  An  acupressure 
pin  is  thrust  through  the  tissues  under  the  base  of  the  tumor,  after  which 
a  stout  cord  is  carried  once  around  the  mass  under  the  ends  of  the  pia, 
and  is  then  tightly  tied.  Sufficient  force  should  be  used  in  making  the 
knot  to  cut  off  all  access  of  blood  to  the  tumor,  which  soon  sloughs  oft, 
leaving  an  ulcer  to  heal. 

It  is  often  well  to  puncture  the  constricted  tumor  with  a  needle  before 
making  the  second  tie,  in  order  to  let  the  blood  and  serum  imprisoned 

therein  escape.  The  tumor  thus  be- 
comes more  flaccid  and  shrunken, 
and  the  string  can,  probably,  be  tied 
more  tightly.  Two  pins  thrust  through 
at  a  right  angle  to  each  other  are  better 
than  a  single  pin,  unless  the  nievus  is 
small.  If  the  string  has  cut  a  groove, 
in  which  it  will  lie  without  slipping 
over  the  top  of  the  tumor,  the  pin  or 
pins  may  be  pulled  out  after  the  knot 
has  been  tied  ;  otherwise,  the  pin  must 
be  left  in  position  until  the  parts  have 
sloughed.  A  second  method  is  to  pass  a  double  ligature  under  the  base 
by  means  of  a  large  ordinary  needle,  or  one  with  a  handle  having  an  eye  in 
the  point.  The  two  halves  of  the  tumor  can  then  be  constricted  by  cutting 
the  string  and  tying  on  each  side. 


Fig.  18. 


Strangulation  of  vascular  tumor  by  a 
pin  and  ligature. 


Fig.  19. 


Ligation  of  vascular  tumor  in  halves  by  a  double  ligature  passed  under  it. 

If  the  tumor  has  an  extensive  area,  the  double  ligature,  of  which  one- 
half  should  be  stained  black  with  ink,  may  be  carried  repeatedly  through 
the  tissues  bv  a  large  ordinary  needle.  Between  each  puncture  of  exit 
and  entrance  a  long  loop  of  the  double  string  must  be  left.  By  cutting 
with  the  scissors  the  stained  threads  on  one  side,  and  the  white  threads  on 
the  other,  a  series  of  ends  are  made  which  can  be  tied  together  to  stran- 
gulate the  tumor  in  sections.  The  adjacent  ends  of  the  separate  portions 
of  the  ligature  may  be  twisted  around  each  other  before  the  loop's  arcs 
are  tied,  if  there  is  danger  of  bleeding  from  the  tying  pulling  the  edges 
of  the  needle's  punctures  apart. 

Occasionally  constricting  a  portion  of  an  angioma  has  set  up  sufficient 
inflammation  to  obliterate  the  whole.  The  subcutaneous  ligation  of  the 
whole,  or  of  sections  of  the  tumor,  may  be  done  by  carrying  a  wire  around 
the  crrowth  in  the  same  wav  as  described  in  the  treatment  of  varicose  veins. 


MYOMAS,    OR    MUSCULAR    TUMORS, 


99 


This  plan  is  well  adapted,  perhaps,  to  su])cutaneous  angioma,  which  may 
possibly  atrophy  without  causing  ulceration  and   scarring.    The  needle 
must,  of  course,  be  reentered  every 
time  at  the  orifice  of  exit.  Fig.  20. 

The  third  method  of  strangulation 
is  a  combination  of  the  other  two. 
First  thrust  a  pin  under  the  mass, 
then  pass  a  needle  carrying  a  double 
ligature  under  the  pin  and  at  a  right 
angle  to  it.  The  two  halves  of  the 
growth  can  then  be  tied,  and  the 
ligature  will  not  slip  over  the  sloping- 
edge  of  the  tumor.  All  of  these 
operations  must  be  carried  out  with 
antiseptic  care. 

Excision  of  angiomas  is,  as  a  rule, 
I  think,  the  best  treatment.  The 
tumor  is  thoroughly  eradicated,"  the 
wound,  if  aseptic,  heals  more  rapidly 
than  the  ulcer  left  after  ligation,  and 
there  is  not  the  offensive  sloughing 
mass  that  remains  unseparated  for 
many  days  after  ligation.  Hemor- 
rhage of  a  serious  character  is  avoided 
by  making  the  incision  beyond  the 
margins  of  the  growth.  When  the  spongy  mass  of  vessels  is  removed, 
sutures  are  applied  and  the  wound  treated  as  after  removal  of  any  other 
tumor.  The  method  much  used  by  Levis,  of  Philadelphia,  to  prevent 
hemorrhage  during  the  removal  of  these  and  other  tumors,  when  even 


Ligation  of  large  vascular  tumor  in  sec- 
tions. The  corresponding  loops  of  the 
black  and  white  threads  are  tied  to 
gether. 


Fig.  22. 


Fig.  21. 


Ligatures  inserted  subcutaneously 
around  the  base  of  a  vascular  tumor 
before  being  tied.     (Bryant.) 


Method  of  ligating  a  vascular  tumor 
in  halves  by  means  of  a  pin  and  liga- 
tui'es.     (Bryant.) 


moderate  bleeding  is  undesirable,  is  worthy  of  notice.  Before  making 
his  first  incision  he  introduces  deeply  through  the  tissues  surrounding  the 
growth,  and  at  some  distance  from  it,  numerous  long  acupressure  pins, 


100  TUMORS.  '( 

and  then  constricts  the  tissues  and  aft'erent  vessels  by  strong  cords  tied 
around  the  ends  of  these  pins,  as  in  the  pin  or  harelip  suture.  If  the 
location  is  not  convenient  for  using  the  pins,  he  carries  strong  cords 
through  the  tissues  by  means  of  specially  made  needles  six  or  eight 
inches  long,  and  ties  the  ends  of  the  cords  on  the  surface  of  the  skin. 
The  access  of  blood  to  the  region  of  operation  is  thus  more  or  less  com- 
pletely prevented.  After  the  incisions  have  removed  the  tumor,  the  pins 
or  strings  are  removed  one  at  a  time,  and  the  bleeding  arteries  ligated 
systematically.  This  method  is  easily  apj)lied,  and  requires  no  special 
skill  for  its  successful  employment  if  the  surgeon  only  place  the  pins  or  liga- 
tures at  a  sufficient  distance  from  the  growth  to  allow  room  for  incision 
to  be  made  entirely  outside  of  its  limits.  The  cord  must  be  strong,  and 
tied  with  much  force.  I  have  broken  strong  fishing-line  in  tying  a  knot 
before  operating  in  this  manner. 

Lymphangiomas  may  be  treated  by  ligation  and  excision,  as  described 
for  the  removal  of  arterial  and  venous  tumors,  if  their  extirpation  is  de- 
manded. 

Papillomas,  or  Papillary  TuMOits. — These  growths  resemble,  and 
are  usually,  hypertrophies  of  the  papillae  of  the  part,  and  are  covered  by 
the  variety  of  epithelium  which  belongs  to  the  region.  They  seem  to 
owe  their  origin  to  direct  inflammatory  irritation,  and  are  of  slow  growth, 
though  they  may  attain  considerable  bulk  by  coalescence  of  several 
smaller  masses.  When  the  epithelium  is  abundant  enough  to  cover  the 
numerous  papillse  and  fill  in  the  crevices  between  them,  the  tumor  is 
somewhat  smooth ;  but  usually  the  various  papillje  and  their  branching 
outgrowths  are  separate,  and  give  the  growth  a  ragged  or  caulifiower 
appearance.  Papillary  tumors  occur  upon  cutaneous,  mucous,  and 
serous  surfaces,  and  present  characteristics  depending  upon  location. 
Sometimes  they  become  pedunculated,  and  constitute  one  form  of  poly- 
poid tumor.  Warts,  as  well  as  many  horny  growths  and  corns,  are 
cutaneous  papillomas.  These  have  a  hardened  epithelium,  except  when 
ke])t  moist,  as  soft  corns  are,  and  possess  limited  vascularity.  The 
papillary  tumors  found  about  muco-cutaneous  junctions  and  upon  mucous 
membranes  are  larger,  non-vascular,  and  softer.  They  occur  especially 
about  the  anus  and  genitals,  where  irritating  discharges  cause  their  ex- 
hibition, and  are  also  found  in  the  bladder,  larynx,  etc.  Serous  papil- 
lon)as  are  met  upon  the  synovial  membrane  of  inflamed  joints.  The 
soft  variety  of  pajiillary  tumor  may  become  the  seat  of  ulceration  or 
hemorrhage.  ^lany  such  excrescences  about  the  anus  and  genitals  were 
formerly  described  as  syphilitic,  but  they  have  no  specific  origin,  except 
in  so  far  as  the  irritation  (jf  the  mucous  membrane  may  in  some  cases  be 
the  result  of  a  venereal  discharge.  Any  other  chronic  irritating  secretion 
will  induce  similar  growths. 

A  papilloma  consists  of  a  projection  of  connective  tissue,  usually  quite 
full  of  small  round-cells,  surrounding  a  loop  or  plexus  of  capillaries,  and 
covered  by  a  layer  of  epithelium.  Papillary  tumors  are  benign,  having 
the  epithelium  only  on  the  surface,  and  not  distributed  through  the  mass, 
as  in  epitheli(»mas.  They  may  become  malignant,  however,  by  transforma- 
tion into  e])itheli()ma.  Warts  of  a  pigmented  kind  occur  frequently  in 
the  aged.  They  should  not  be  irritated,  as  they  may  thus  be  excited  to 
assume  malignant  tendencies. 

Papillomas  on  mucous  surfaces  may  give  rise  to  hemorrhages;  and  in 
the  bladder  and  urethra  may  obstruct  urinary  evacuation. 

Papillomas  should  be  treated  by  removal  \\ith  caustics,  ligatures,  or 


ADENOMAS,  OR  GLANDULAR  TUMORS. 


101 


excision.  Occasionally  the  hemorrhage  which  follows  excision  will  be 
severe.  Powdered  tannic  acid  smeared  over  the  bleeding  surface  is  a 
good  styptic,  especially  if  combined  with  pressure  for  an  hour  or  more. 

Adenomas,  or  Glandular  Tumors. — -Glandular  tumors  consist  of 
such  tissue  as  is  found  in  secreting  glands  (the  simple  tubular  glands  of 
the  mucous  membranes  and  the  compound,  or  racemose,  glands,  such 
as  the  mamma  and  pai'otid) ;  but  the  tissue  is  not  capable  of  performing 
function  as  a  gland.  They  must  not  be  confounded  with  lymphatic  gland 
tumors,  which  have  a  very  different  structure  and  are  called  lymphomas. 
The  tubular  adenoma  is  found  originating  from  mucous  membrane,  as  of 
the  vagina,  rectum,  stomach,  and  is  often  so  closely  allied  to  epithelioma 
that  a  distinction  is  well-nigh  impossible.  Racemose  adenomas  occur  in 
the  breast  especially,  and  are  often  associated  with  fibrous  and  sarcomatous 
tissue,  thus  forming  compound  tumors. 

Adenomas  are  of  slow  growth,  may  be  lobular  in  form,  are  quite  firm 
unless  undergoing  cystic  degeneration,  are  usually  surrounded  by  a  cap- 
sule, and,  when  uncomplicated  w^ith  other  morbid  growths,  are  benign. 
They  sometimes  undergo,  in  places,  fatty  or  cheesy  transformation. 
Glandular  tumors  of  mucous  membrane  sometimes  become  pendulous  and 
thus  constitute  a  form  of  polypoid  tumor. 


Fig.  23. 


Adeno-sarcona. 
rfz-om  dieastj 


Adenom.a 
from  ireast, 
tAeyollicles      .  \ 
^rowi//j/  cystic) 


*c 


Adeno  -Mi/oDoma 
i^^'Tom  lix-east) 


>^  Adenoma 
J-//  /'^/j'om  s^f/i   . 
',      o/yo?-e  arm) 


,<" 


'K^/ 
^ 


AdeTW-J'ibrO' 
sarcoTTia 


Sections  of  adenoma  showing  acini.     (Bryant.) 

Tubular  adenomas  show  under  the  microscope  tubules,  resembling  the 
follicles  of  the  intestine,  lined  with  epithelial  cells ;  racemose  adenomas 
exhibit  a  series  of  pockets,  or  acini,  lined  with  one  or  more  rows  of  epi- 
thelium. Between  the  acini  is  connective  tissue  in  varying  quantity, 
sometimes  containing  numerous  cells. 

True  adenoma  is  benign,  but  its  frequent  association  with  sarcoma, 
and  its  tendency  at  times  to  become  epitheliomatous,  render  its  extirpa- 


102  TUMORS. 

tion  usually  desirable ;  especially  is  this  the  case  because  of  the  liability 
of  error  in  clinical  diagnosis. 

III.  Tumors  ivhose  general  structure  or  type  is  that  of  the  wideveloped 
tissue  of  the  emhr I/O  (^Sarcomas). — Tumors  consisting  of  connective  tissue 
similar  to  that  found  in  the  human  embryo  are  called  sarcomas,  and  pre- 
sent variations  according  to  the  peculiarities  of  the  cells  and  intercellular 
substance.  The  connective  tissue  of  the  embryo,  before  it  is  developed 
into  the  mature  connective  tissue  of  the  foetus,  consists  of  numerous  snuill, 
round  cells,  with  a  very  small  (juantity  of  soft  and  homogeneous  material 
between  them.  As  the  connective  tissue  becomes  more  mature,  the  cells 
decrease  in  nund^er  and  assume  an  elongated  shape,  while  the  intercellular 
material  spoken  of  becomes  fibrous.  This  maturing  connective  tissue 
finally  develops  into  the  perfect  connective  tissue,  fibrous  tissue,  cartilage, 
and  bone  of  the  fcetus  and  child. 

Sarcomatous  growths  are  formed  then  of  embryonic  connective  tissue, 
which,  instead  of  maturing,  continues  to  exist  and  to  reproduce  itself, 
thus  causing  progressive  increase  of  the  tumor.  Small  portions  of  the 
tumor  occasionally  reach  a  higher  development  and  become  fibrous  tissue, 
cartilage,  or  bone,  thus  producing  a  mixed  tumor;  but  this  is  not  general 
or  usual.  The  cells  of  sarcomas  may  be  round,  spindle-shaped,  or  very 
large  and  irregular.  They  are  closely  packed  together  with  very  little 
intercellular  substance,  which  varies  from  a  homogeneous  fluid  to  a  some- 
what granular  or  fibrillated  material  having  considerable  firmness,  but 
which  usually  intervenes  between  all  the  cells,  and  does  not  allow  them  to 
congregate  together  in  groups. 

Fin.  24.  Fig.  25. 


Round  cells.    X  350.    (Grekx.)  Spindle  cells.    X  350.     (Green.) 

These  cells  may  all  occur  in  one  tumor,  but  the  form  which  pre- 
dominates gives  name  to  the  variety,  viz. :  round-cell,  spindle-cell,  and 
giant-cell  sarcoma.  The  round  cells  are  either  identical  in  a])pearance 
with  white  blood-cells,  or  they  may  have  an  indistinct  nucleus  and  bright 
nuclei. 

The  s])indle  or  fusiform  cells  are  oblong,  terminate  in  fibrils,  and  have 
a  long  elliptical  nucleus,  with  or  without  a  nucleolus.  The  large  irregular 
or  giant  cells,  called  myeloid  cells  becau.se  they  resemble  the  cells  of  foetal 
marrow,  are  very  much  larger  than  the  others,  and  are  irregularly  spherical 
with  perhaps  several  prolongations,  and  contain  many  oval  nuclei  with 
bright  nucleoli.  They  may  not  actually  predominate  in  the  tumor,  but 
their  presence  is  so  evident  that  they  give  name  to  the  variety  in  which 
they  are  seen.  The  bloodvessels  in  sarcomas  are  numerous,  and  on 
account  of  the  small  amount  of  matrix  are  scarcely  separated  from  direct 
contact  with  the  cells. 


SARCOMAS.  103 

Sarcomas  always  develop  from  connective  tissue ;  hence,  they  have  a 
general  distribution  and  are  found  originating  from  muscular  fascias, 
periosteum,  lymphatic  glands,  and  marrow  of  bones,  as  well  as  from  the 
ordinary  connective  tissue  beneath  the  skin  and  the  cellular  tissue  of  the 
viscera.  They  infiltrate  the  surrounding  structures  and  thus  extend  by 
cellular  invasion.  There  may  be  a  sort  of  capsule,  though  the  growth  is 
usually  diffuse.  Fatty,  cystic,  calcareous,  and  other  degenerations  are 
liable  to  occur  in  portions  of  the  growth ;  and  sometimes  sarcoma  may 
be  combined  with  other  forms  of  tumor.  This  assumption  of,  or  combi- 
nation with,  sarcomatous  elements  accounts  for  the  malignancy  of  certain 
tumors  which  are  usually  classed  as  benign.  This  has  been  referred  to 
when  sjDeaking  of  osteomas  and  chondromas. 


Fig.  26. 


Giant  or  myeloid  cells.     (Green.) 

Sarcomas  are  not  as  common  in  old  age  as  in  the  earlier  period  of  life. 
Many  sarcomas  are  very  malignant,  infiltrating  adjacent  parts,  recurring 
after  removal,  and  finally  producing  secondary  growths  in  the  lungs  and 
other  regions.  The  round  cell  and  the  large  spindle-cell  growths  are 
mu'ch  more  malignant  than  the  small  spindle  or  giant  cell  tumors.  Soft 
and  very  vascular  sarcomas  are  to  be  looked  upon  as  being  probably 
highly  malignant.  Sarcomas  do  not  often  affect  the  lymphatic  glands, 
while  the  carcinomas  do  so  Avith  great  frequency.  The  fact  that  the 
bloodvessels  in  sarcomas  are  in  close  relation  with  the  cells  accounts  for 
the  occasional  rapid  development  of  secondary  tumors  without  lymphatic 
involvement.  The  cells  readily  penetrate  the  thin  vessel  walls  and  are 
carried  along  with  the  blood-current.  In  carcinomas,  as  will  be  seen 
later,  the  bloodvessels  run  in  the  fibrous  network,  or  stroma,  at  a  distance 
from  the  cells,  which  lie  grouped  in  alveoli  or  pockets.  Hence,  dissemi- 
nation usually  proceeds  along  the  lymphatic  channels  before  infection  by 
the  blood-current  takes  place. 

Bound- cell  sarcomas  present  round  cells  which  are  similar  to  granula- 


104 


TUMORS. 


tion  cells,  which  are  larger  than  leucocytes  and  have  an  indistinct  nucleus 
with  nucleoli.     Those  round  cells  are  seen  lying  in  a  soit  honioirencous  or 

granular  intercellular  substance 
!  .      -  or  matrix.     The  structure  is,  in 

fact,  that  of  the  primitive  tissue 
of  the  embryo. 

Round-cell  sarcomas  are  soft, 
and  gray  or  pinkish  in  color 
u|)ou  section  ;  furnish  a  juice 
when  scraped;  are  very  vascular, 
and  hence,  are  often  stained  by 
riii)ture  of  vessels  and  are  liable 
to  contain  blood  cysts.  They 
raf)idly  infiltrate  neighboring 
parts,  give  rise  to  distant  sec- 
ondary growths,  may  even  in- 
volve lymphatic  glands,  and  in 
many  other  characteristics  re- 
resemble  clinically  the  form  of 
carcinoma  called  encephaloid. 
The  microscopic  appearances 
serve  to  distinguish  them  from  encephaloid  with  its  stroma  and  grown-up 
cellular  elements.  Round-cell  sarcomas  are,  of  course,  as  seen  by  their 
above-mentioned  tendencies,  very  malignant.  Glioma,  the  round-cell 
tumor  found  in  the  brain,  retina,  and  cranial  nerves,  is  a  sarcoma.  There 
is  a  round-cell  sarcoma  which  shows  an  excess  of  intercellular  structure 
in  certain  portions  of  the  growth,  so  that  there  is  a  resemblance  to  the 
stroma  of  carcinomas.     This  has  been  called  the  alveolar  sarcoma. 

Spindle-cell  Sxrcomas. — These  are  the  most  frequently  found    of  the 
sarcomas,  and  consist  of  elongated  cells  with  distinct  oval  nuclei  and 


Small,  roiiii(l-(;ell    sarooiiia,  showing  vessels 
with  mere  embrvoiiic  wall.     X  400. 


Fig.  29. 


^<5t#      , 


'^'rWiWIl. 


^A\^^^^^ik 


Large  spindle-cell  sarcoma.     Some  cells 
teased  apart.     (Virchow.) 


Giant-cell  sarcoma.  X  280.    (Holmes.) 


nucleoli.  The  cells  lie  close  together  in  parallel  rows  with  little  interven- 
ing substance,  and  sometimes  give  rise  to  a  fibrous  appearance  until  they 
have  been  teased  apart  to  show  their  characteristic  shape.  If  the  spindle 
cells  are  small  the  growth  is  rather  hard  and  probably  is  surrounded  by 


CARCINOMAS.  105 

a  capsule.  Although  it  will  recur  after  removal  and  will  spread  by  in- 
filtration of  surrounding  tissues,  it  has  little  disposition  to  infect  the 
internal  organs  and  possesses  much  less  malignancy  than  the  large  spindle- 
cell  variety,  which  is  soft,  more  vascular,  and  exceedingly  liable  to  give 
rise  to  distant  secondary  tumors.  Sometimes  the  cells  are  so  broad  as  to 
be  really  oval  in  form.  The  small-cell  growths  are  the  recurrent  fibroid 
tumors  of  the  older  writers. 

Sometimes  spindle-cell  sarcomas  contain  pigment  granules  deposited  in 
the  cells.  This  occurs  especially  w^hen  the  tumor  arises  from  a  tissue 
containing  pigment,  as,  for  example,  the  choroid  coat  of  the  eye.  These 
melanotic  sarcomas  are  very  liable  to  induce  secondary  pigmented  growths 
in  the  internal  organs,  and  are,  therefore,  very  malignant,  even  if  they 
have  less  disposition  to  local  extension  than  some  other  forms.  This 
tumor  a  few  decades  ago  was  often  denominated  black  cancer. 

Calcareous  and  osseous  degeneration  occasionally  occurs  ;  then  the  term 
osteoid  sarcoma  is  used.  This  is  very  different  from  the  benign  growth 
called  osteoma. 

Giant-cell  or  myeloid  sarcomas. — These  tumors  usually  arise  from  bone 
and  especially  from  the  marrow.  They  contain  large  multinucleated 
cells,  like  those  of  foetal  marrow,  associated  with  spindle  cells,  and  show 
little  substance  between  the  cells.  The  nuclei  of  the  myeloid  cells  con- 
tain bright  nucleoli.  Myeloid  sarcomas  are  usually  quite  hard,  may  be 
vascular,  and  frequently  contain  cysts.  When  they  grow  from  the  me- 
dullary canal  the  bone  is  expanded  before  them,  and  therefore  manipula- 
tion of  the  tumor  may  cause  a  crackling  noise.  They  frequently  occur 
in  the  extremities  of  the  long  bones  and  in  the  jaws.  They  are  less  ma- 
lignant than  the  round  and  spindle-cell  varieties  of  sarcoma. 

IV.  Tumors  ivhose  general  type  is  that  of  epithelial  tissue  {Carcinomas.^ 
— The  carcinomas  consist  of  a  fibroid  network  or  stroma  within  the 
meshes  or  alveoli  of  which  numerous  cells  of  an  epithelial  type  (epithe- 
lioid cells)  are  crowded  together  without  any  intermediate  substance.  A 
carcinoma  may  be  readily  illustrated  by  a  piece  of  sponge  (the  stroma) 
within  the  cavities  (alveoli)  of  which  numerous  grains  of  sand  (cells)  are 
grouped.  A  sarcoma,  on  the  contrary,  is  represented  by  a  quantity  or 
mass  of  sand  of  which  the  grains  (cells)  all  lie 
closely  together  with  no  sponge  or  stroma  to  form  Fig.  30. 

distinct  spaces  (alveoli)  for  their  reception. 

The  cells  of  carcinomas  are  about  five  times 
as  large  as  a  red  blood-corpuscle,  have  a  variety 
of  shapes  on  account  of  their  mutual  pressure, 
possess  large,  well-marked  nuclei  and  nucleoli, 
and,  though  there  is  no  intercellular  substance 
between  the  cells,  have  some  fluid  filling  the 
.spaces  between  them.  The  cells  frequently  show 
molecules  of  fat  within  them  due  to  fatty  de-  cells  from  a  scirrhous 
generation,  and  indeed  the  cells  may  be  entirely  carcinoma  of  breast,  x  350. 
•destroyed,  so  that  only  the  free  nuclei  remain.  (Geeen.) 

It  must  be  borne  in  mind  that  similar  cells  are 
seen  in  these  morbid  growths  as  in  normal  tissues.     It  is  the  characteristic 
arrangement  of  the  cells,  the  variety  of  their  shape  and  the  stroma  that 
distinguish  carcinomas.     There  is  no  special  carcinoma  cell. 

The  fibrous  network  or  stroma  of  carcinoma  is  a  more  or  less  fibrillated 
structure  so  interlaced  as  to  leave  numerous  communicating  irregular 
spaces  called  alveoli,  within  which  the  cells  already  described  are  impris- 


IOC  TL'MOKS. 

oned.  The  amount  of  stroma  varies  very  much  and  with  its  abundance 
the  liardne,<s  of  the  tumor  increases.  It  sometimes,  especially  if  of  rapid 
development,  contains  in  its  own  structure  a  few  cell^^.  Iii  the  r^troma, 
forming  as  it  does  the  walls  of  the  alveoli,  the  bloodvessels  ramify.     Hence 

the  cells  of  carcinoma  are  sepa- 

^"*'^'-  rated  from   the  vessels  and   do 

^ ,--,:' ^] ':■-.■  ::':'  not    as    readily  as    in    sarcoma 

/  enter     the    blood-current    and 

y'  :  cause  rapid  dissemination  of  the 

/        growth.    The  lynij>liatic  vessels, 

however,  which  accompany  the 

y\^       bloodvessels  in  the  stroma,  open 

.^  •'       into  the  alveoli,  and  thus  readily 

'  J^,i?^/  7  •       allow  entrance  of  cells  into  the 

';^   ■  /      :^:c.-^        lymphatic  stream.  Thisaccounts 

^i  y  for  the  early  involvement  of  the 

_^^-;    .-^ 4^  •  'J'  neighboring  lymphatic    glands 

in   cases  of  carcinoma,  and    its 

Stroma  troni  carcinoma.  X  220.  (Holmes.)        more  frequent  occurrence  than 

in  sarcomas. 
Carcinoma  cells  originate  from  preexisting  epithelium,  and  therefore 
carcinomatous  growths  occur  only  where  e])ithelium  exists,  as  in  the  glands 
and  cutaneous  and  mucous  structures.  This  at  least  seems  to  be  the 
opinion  with  most  authority  in  its  favor.  After  a  time  the  epithelial  cells 
burst  through  the  epithelial  basement  membrane  from  which  they  origi- 
nated and  thrust  themselves  among  other  tissues.  This  has  probably  given 
rise  to  the  opinion  that  they  developed  from  other  than  epithelial  struc- 
tures. The  stroma  of  carcinoma  is  partly  newly  developed  tissue  and  partly 
the  previously  existent  connective  tissue  of  the  part. 

The  degenerative  process  occurring  in  carcinomas  most  frequently  is 
fatty  transformation  which  is  always  observable  in  a  greater  or  less 
degree.  It  sometimes  converts  the  tumor  into  a  pulpy  mass.  Cystic  de- 
generati(m  sometimes  occurs.     Abscess  may,  though  rarely,  occur. 

The  structure  and  clinical  characteristics  of  the  carcinomas  have  caused 
their  division  into  these  varieties : 
Acinous  Carcinoma : 

o.  Scirrhus,  or  Chronic  Carcinoma. 
h.  Encephaloid  or  Acute  Carcinoma. 
Epithelial  Carcinoma : 

«.  Squamous  Epithelioma. 
h.  Columnar  Cell  Epithelioma. 
Any  of  these  may  undergo  colloid  degeneration  and  become  the  so-called 
Colloid  or  Gelatiniform  carcinoma. 

The  clinical  characteristics  of  the  carcinomas  are  important.  They  are 
exceedingly  malignant,  though  epithelioma  is  usually  less  so  than  encepha- 
loid and  scirrhus.  They  differ  from  sarcomas  in  that  they  generally  infect 
the  neighboring  lymphatic  glands  and  do  not  produce  secondary  tumors 
in  the  internal  viscera  until  after  the  lymphatic  glands  in  the  vicinity  of 
the  primary  gi'owth  have  been  affected  for  a  considerable  time.  Sarcomas, 
on  the  other  hand,  rarely  involve  the  lymphatics,  but  rapidly  appear  in 
the  viscera,  because  of  their  dissemination  by  means  of  the  bloodvessels, 
which  have  thin  walls  and  ramify  among  the  cells  instead  of  running  in  a 
stroma. 

Epithelioma  much  less  rarely  reproduces  itself  in  the  viscera  than  the 


CARCINOMAS.  107 

Other  forms  of  carcinoma,  though  it  ulcerates  earlier.  It  usually,  how- 
ever, infiltrates  the  adjacent  tissue  and  involves  the  neighboring  glands. 
The  more  rapid  and  the  more  vascular  a  carcinoma  is,  the  greater  are  its 
malignant  qualities ;  hence,  encephaloid  may  be  considered  as  having 
the  greatest  degree  of  malignancy.  The  secondary  growths  produced 
by  carcinomas  are  usually  of  the  same  varieties  as  the  primary  tumor.  If 
a  carcinoma  is  incised,  a  comparatively  abundant  whitish  juice  can  be 
scraped  from  the  cut  surface.  This  consists  of  the  fluid  and  cellular  ele- 
ments of  the  growth. 

Ulceration,  sometimes  attended  by  hemorrhage,  is  of  frequent  occurence 
in  carcinomatous  disease.  Pain,  of  a  darting  character,  is  a  not  infrequent 
symptom. 

The  word  "  cancer  "  was  formerly  much  employed  to  designate  malig- 
nant growths.  This  Avas  before  the  days  of  accurate  pathological  and 
microscopic  investigation.  Now,  some  authors  attempt  to  limit  the  term 
to  the  class  "carcinoma."  This  produces  an  unnecessary  confusion,  for 
"  cancer  "  has  and  can  have  no  accepted  scientific  definition.  It  has  no 
greater  etymological  value  in  the  scientific  surgery  of  the  present  time 
than  has  "hives"  in  dermatology,  or  "amaurosis"  in  ophthalmology. 
The  word,  therefore,  should  not  be  retained  in  surgical  literature. 

Scirrhus,  or  chronic  or  hard  carcinoma,  grows  very  slowly,  is  very 
hard,  is  apt  to  be  nodular,  seldom  attains  a  large  size,  and  occurs  usually 
in  rather  advanced  adult  life.  At  first  it  is  unconnected  with  the  over- 
lying skin,  but  soon  becomes  attached  to  the  integument,  and  causes 
puckering  and  retraction  thereof.  As  the  disease  advances  the  lymphatic 
glands  in  the  vicinity  become  enlarged  and  ulceration  of  the  skin  over 
the  primary  growth  occurs,  producing  an  ulcer  with  ragged  and  nodulated 
irregular  edges,  secreting  a  foul  mixture  of  sanious  pus  and  blood.  The 
pain  in  scirrhus,  when  present,  is  of  a  shooting  or  neuralgic  character. 
Scirrhus  is  most  frequent  in  the  female  mammary  gland,  and  in  the  various 
parts  of  the  alimentary  tract.  When  the  internal  organs  are  involved 
secondarily,  it  may  assume  the  form  of  encephaloid.  Section  of  a  scirrhous 
mass  causes  creaking  as  the  knife  divides  the  hard  fibroid  tissue,  and 
shows  a  whitish  shining  surface,  usually  traversed  by  fibrous  lines,  and 
often  concave  on  account  of  contracting  influences. 

Fig.  32.  Fig.  33. 


Section  of  scirrhus  taken  from  newly  developed  por-         Section  from  interior  of  scirrhus, 
tion  of  tumor.     X  200.     (Geeex.)  showing  atrophy  of  cells  and 

diminution  in  size  of  alveoli. 
X  200.     (Greej,-.) 

Microscopic  examination  reveals  a  very  large  amount  of  stroma.  This, 
by  contraction  and  hardening,  finally  causes  atrophy  and  disappearance 
of  the  epithelial  cells,  and  almost  obliterates  the  alveoli.  Hence,  the 
interior,  or  older  portion  of  a  scirrhoma,  approximates  in   appearance 


108  TUMORS. 

fibrous  tissue,  Avhile  the  exterior  or  newly  developed  structure  shows  the 
alveoli  and  the  groups  of  epithelioid  cells. 

Encephaloid,  or  acute  or  soft  carcinoma. — This  morbid  growth  is  soft, 
having  the  consistence  of  brain  tissue,  grows  rapidly  ;  is  very  vascular, 
frequently  showing  large  veins  traversing  the  overlying  integument,  and 
when  it  ulcerates,  gives  rise  to  a  fungous  protrusion  which  is  the  seat  of 
hemorrhage.  Sometimes  ])ulsation  is  perceptible,  on  account  of  the  numer- 
ous large  arteries  in  its  structure.  Encephaloid  is  not  as  frequent  a 
growth  as  scirrhus,  and  it  is  found  usually  in  the  viscera  as  a  secondary 
growth  following  a  primary  scirrhus  of  external  parts.  It  does  occur, 
however,  primarly  at  times,  especially  in  the  testicle  and  breast.  ^lany 
tumors  of  the  eye  and  of  the  bones  occurring  particularly  in  young  adults 
or  children,  formerly  described  as  encephaloid  disease,  are  now  recognized 
as  sarcomas.  On  section  encejjhaloid  tumors  show  a  brain-like  pulpy 
substance  stained  by  blood  extravasations  and  sometimes  quite  fluid  from 
fatty  degeneration. 

Encephaloid  can  scarcely  be  described  as  an  entirely  distinct  growth 
from   scirrhus;  but  its  softness,  its  greater  rapidity  of  growth,  its  less 

amount  of  stroma  and  absence  of  con- 

FiG.  34.  tractile  tendencies,  its  vascularity,  and 

its  abundance  of  cells  rapidly  undergo- 

-- ^'',j^^p%.-j_^  ing  fatty  degeneration  warrant  its  desig- 

V     ,_,,^i^  '       nation  by  a  separate  name. 

^;i^^^5i  '^-  Under  the  microscope  the  observer 

■  ^ ''      finds  large   alveoli,   surrounded    by    a 

_(<!f,  ^ii  -      limited  amount  of  stroma,  and  contain- 

^'''    '  ,  1^;^        ing  rather  large  cells,  undergoing  fatty 

g;  -^'<   .       change,  accompanied    by    many    free 

,-  nuclei. 

ffi,  Colloid,    or   gelatinous   carcinoma. — 

r„T^.  r  Colloma    is    a   soft,    jelly-like    tumor, 

" 'v|a;5vvi-!  •;;."' :v^^      ■^"^:  -  occurring   most   frequently  in  connec- 

' '^  tion    with    the    peritoneum,  intestines, 

Encephaloid  carcinoma,  showing  and  stomach.  It  is  a  colloid  or  mu- 
large  alveoli  and  small  amount  of  coid  degeneration  of  scirrhus,  encepha- 
stroma.    X  200.    (Green.)  loid    or   epithelioma.     Lipomas,   chon- 

dromas, myxomas,  sarcomas,  and  other 
growths  undergoing  change  of  a  colloid  or  mucoid  character  may  be  mis- 
taken clinically  for  colloid  carcinoma. 

The  neoplasm  has  still  less  stroma  than  encephaloma,  and  the  alveoli 
are  large  and  very  distinct,  because  of  their  distention  with  a  mucilaginous 
or  glue-like  material.  This  colloid  substance  is  transparent  and  colorless, 
or  sometimes  yellowish,  and  for  the  most  part  structureless,  though  a  few 
epithelioid  cells  are  seen.  These  cells  are  large  and  distended  with  the 
gelatinous  material  similar  to  that  surrounding  them.  At  times  they  differ 
little  from  ordinary  carinoma  cells.  Sometimes  they  have  a  lamellar 
surface. 

Epithelioma,  or  skin  carcinoma.  Squamous  epithelioma. — This  is  a  more 
distinct  variety  of  carcinoma  than  the  others,  though  it  does,  at  times, 
approach  scirrhus  in  its  characteristics.  It  usually  occurs  at  a  muco- 
cutaneous junction  such  as  the  lip,  eyelid,  ala  of  the  no.se,  anus,  and 
prepuce ;  and  appears  first  as  a  small  nodule  under  the  skin  or  as  a  scab 
or  an  ulcerated  abrasion  or  fissure.  It  not  infrequently  arises  at  the 
situation  of  moles  or  warts.     The  tumor  is  quite  firm  and  shows  on  sec- 


CARCINOMAS.  109 

tion  a  whitish  granular  surface  traversed  by  fibrous  bands,  from  which  a 
thick,  curdy  material,  like  sebum,  can  be  pressed.  The  epithelial  nests, 
to  be  described,  can  often  be  seen.  Epithelioma  is  rare  in  young  per- 
sons ;  soon  exhibits  ulcerative  action,  though  of  somewhat  slow  progress  ; 
commonly  implicates  the  lymphatic  glands  but  does  not  often  infect  the 
viscera ;  and  is  traceable  to  traumatic  irritation  of  the  muco-cutaneous 
tissues  more  frequently  than  the  other  carcinomas. 

Fig.  .35. 


'\"^ 


"^^  ■-  \N. 


Colloid  tumor,  showing  large  alveoli  and  colloid  contents.     X  300.     (C4eeen.) 

Fig.  .36. 


A  lobulated  pavement-cell  6L|Uaiuuua  epithelioma  showing  j^early  bodies. 
(Drawn  by  Dr.  Charles  B.  Williams.) 

The  cells  of  ordinary  epithelioma  resemble  the  squamous  epithelium  ot 
skin  and  raucous  membrane,  and  contain  one  or  more  nuclei.  They  may 
be  flattened  by  pressure,  but  have  not  the  varied  shape  of  the  other 
carcinomatous  cells,  nor  do  they  so  readily  assume  degenerative  changes 
of  a  fatty  kind.     They  are  grouj)ed  in  the  alveoli  of  the  stroma,  some- 


110 


TUMORS. 


times  as  tubular  prolongations  or  plugs,  and  tend  to  form  nests  or 
"pearls"  formed  of  concentric  layers  of  flattened  cells,  which  resemble 
the  structure  of  an  onion.  These  epithelial  globes  or  nests  are  very 
characteristic  of  epithelioma,  though  not  essential.  They  grow  down 
from  the  surface  into  the  lymph  spaces  of  the  connective  tissue  like  nails 
or  plugs.  They  merely  signify  that  there  is  a  rapid  growth  of  scjuamous 
epithelium  and  may  occur  in  epidermic  structures  not  carcinomatous. 

The  stroma  is  rarely  so  markedly  alveolar  as  in  the  other  members  of 
the  carcinomatous  group,  and  may  be  (juite  limited  in  amount.  It  is 
represented  by  a  fibrous  like  tissue  or  by  a  tissue  iilled  with  small  round 
cells  surrounding  the  epithelial  nests. 

Columnar  epitheUomn — When  epithelioma  occurs  in  the  intestinal  tract 
the  cells  are  of  the  columnar  or  cylindrical  variety  found  in  the  mucous 
glands  of  these  parts,  appear  in  more  distinct  alveoli,  and  usually  do  not 
form  concentric  nests.     The  growth  closely  resembles  adenoma. 


Columnar  p])itlielionia  ol'  transverse  colon.  One  alveolus  is  cut  obliquely,  the  others 
transversely;  the  epithelium  is  irregular  in  shape  and  size  and  is  sometimes  arranged  in 
more  than  one  layer.     The  stroma  is  fibrous,  containing  small  round  cells.     (Erichskn.) 

Epithelioma  originates  from  the  epithelium  of  the  skin,  mucous  mem- 
branes, and  glands  ;  and  then  the  proliferation  of  ei)ithelium  which  occurs 
causes  invasion  of  the  adjacent  structures,  whether  they  be  connective 
tissue,  muscle,  or  bone.  It  is  the  presence  of  epithelium  in  these  unusual 
localities  that  is  the  essence  of  the  morbid  growth.  Rodent  ulcer  is  a 
form  of  epithelioma. 

V.  Taniors  cou.^idiriff  of  a  sac  with  contenU  (cydoma.s,  or  cystic  tumors). — 
A  cavity  separated  from  neighboring  tissues  by  a  sac  wall  and  having 
fluid,  semi-solid,  or  soft  contents  is  called  a  cyst  or  cystic  tumor. 

Such  tumors  may  result  from  the  development  of  a  sac-like  cavity  in 
tissues  where  no  sac  or  cyst  previously  existed.  These  are  true  tumors  or 
morbid  growths,  and  are  due  to  softening  of  structure,  as  occurs  in  fatty 
and  mucoid  degeneration ;  to  separation  of  connective  tissue  by  a  secretion 
or  deposition  of  fluid,  as  serous  and  blood  cysts;  and  to  the  development 
of  a  sac  around  foreign  bodies  and  parasites.  In  all  these  cases  condensa- 
tion and  irritative  development  of  connective  tissue  lead  to  the  formation 
of  a  circumscribing  capsule  or  sac  wall. 

Cysts  are  more  frequently  developed  by  slow  accumulations  within  a 


CYSTIC    TUMORS.  Ill 

dilation  of  a  preexisting  cavity  or  duct.  These  are  not  true  tumors,  but 
are  usually  conveniently  considered  as  such  in  connection  with  the  form 
just  mentioned.  The  contents  are  the  natural  products  or  secretions  of 
the  part,  more  or  less  altered  by  the  changed  conditions  to  which  they 
are  subjected.  Such  cysts  are  developed  when  the  duct  of  a  secretory 
gland  becomes  occluded,  as  is  the  case  in  sebaceous,  mucous,  salivary,  and 
other  retention  cysts ;  when  a  ductless  cavity  secretes  more  fluid  than  the 
absorbents  can  remove,  as  in  hydrocele,  bunion,  and  bursal  tumors ;  when 
the  blood  is  poured  into  a  cavity,  as  in  hsematoceles. 

The  wall  of  a  cyst  may  be  thick  or  thin,  tough  or  friable,  slightly  or 
:firraly  adherent  to  surrounding  tissues,  and  is  developed  by  condensation 
and  new  growth  of  the  circumscribing  connective  tissue.  In  the  second 
variety  of  cystic  tumors  the  wall  presents  the  features  of  the  gland  or 
membrane  from  which  it  was  developed,  and  has  a  similar  epithelial  lining. 
Cysts  may  contain  serum,  saliva,  milk,  semen,  sebum,  blood,  and  other 
materials,  and  often  take  their  name  from  the  contents. 

The  congenital  cysts,  which  consist  of  a  wall  resembling  skin  contain- 
ing epithelial  structures,  and  those  cysts,  enclosing  teeth  and  bones,  found 
in  the  abdomen  and  supposed  to  be  imperfectly  developed  ova,  are  called 
dermoid  cysts. 

The  hydatid  cyst  is  a  peculiar  tumor  due  to  the  presence  in  the  tissues 
of  a  parasite.  This  parasite  is  the  undeveloped  taenia  echinococcus,  which 
infests  animals  of  the  canine  family  but  never  progresses  to  full  maturity 
in  the  human  subject.  The  ovum  having  been  introduced  with  food  into 
the  human  system,  develops  as  far  as  its  cystic  stage.  The  irritation  due 
to  the  parasite  in  the  tissues  causes  the  formation  of  a  sac  or  cyst  wall 
from  the  surrounding  parts:  within  this  lies  the  parasite,  which  is  itself  a 
distended  sac  without  any  head,  hence  called  an  acephalo-cyst.  It  con- 
tains a  ti-ansparent,  non-albuminous  or  almost  non-albuminous  liquid  of 
low  specific  gravity,  in  which  are  floating  heads  or  the  booklets  belonging 
to  the  heads  of  this  form  of  worm.  These  heads  are  called  echinococci.  The 
echinococci  may  be  adherent  to  the  inner  wall  of  the  bladder  like  para- 
sites. Hydatid  tumors  occur  most  frequently  in  the  liver,  lungs,  muscles, 
and  subcutaneous  tissue. 

Various  changes  occur  in  cystic  tumors.  Thus,  the  contents  may 
become  inspissated,  fatty,  or  calcareous,  and  the  wall  may  calcify,  ossify, 
or  even  undergo  cystic  or  other  degenerations.  Sometimes  inflammation 
of  the  tumor  supervenes,  which  leads  to  suppuration,  discharge,  or  ab- 
sorption of  the  contents,  and  cure  by  granulation. 

Occasionally,  instead  of  cicatrization  occurring,  a  foul  chronic  ulcer  is 
left. 

A  cystic  tumor  with  one  cavity  is  called  simple  or  unilocular ;  one 
with  several  cavities,  compound  or  multilocular.  It  must  be  remembered 
that  many  of  the  tumors  previously  described  may  undergo  cystic  de- 
generation by  mucoid  or  fatty  change  taking  j^lace  in  their  interior. 

The  treatment  of  cystomas  consists  in  their  removal  or  their  obliteration 
by  evacuation  of  contents  and  destruction  of  cyst  walls.  True  cystomas 
are  benign,  but  may,  as  other  malignant  growths,  cause  death  by  their 
situation  and  size.  If  they  are  excised  every  portion  of  the  cyst  wall 
must  be  removed,  lest  the  part  remaining  become  the  starting-point  for 
a  similar  tumor.  Cystic  sarcomas  and  other  tumors  that  have  undergone 
cystic  degeneration  must  be  treated  as  growths  of  their  own  class. 

Obliteration  of  cysts  may  be  accomplished  by  tapping,  internal  scarifi- 
cation, injection,  and  incision.     If  the  contained  fluid  is  not  viscid  it  may 


112  TUMORS. 

be  \vith<lra\vn  with  a  trocar  or  aspirator;  this  causes  colhipse  of  the  sac. 
Usually  the  cyst  refills,  but  occasionally  the  irritation  resulting  from  the 
puncture  is  sufficient  to  cause  plastic  iuHaniniation  of  the  interior  of  the 
cyst  and  adhesion  of  the  walls.  Thus,  obliteration  of  the  cavity  and  cure 
result.  The  cure  may  at  times  be  accomplished  by  scarifying  the  internal 
surface  of  the  cyst  wall  with  a  tenotome  or  long  needle  thrust  into  it 
at  one  or  at  several  points  without  evacuating  the  fluid,  which  escapes 
into  the  surrounding  tissues  and  is  absorbed,  or  undergoes  absorption 
during  the  progress  of  the  resulting  inflammation.  This  method  is  very 
satisfactory  in  treating  hydrocele  in  infants.  Multiple  puncture  and 
abrasion  of  the  vaginal  tunic  with  a  needle  seldom  fiiil  to  cure  such  cases. 
When  tapping  or  scarification  fails  to  induce  obliteration  of  cysts  with 
liquid  contents,  it  becomes  necessary  to  inject  into  the  cavity  some  irri- 
tating fluid  to  set  up  inflammation  of  a  plastic  grade.  The  best  agent  is 
carbolic  acid  licpiefied  by  moderate  heat  or  a  few  drops  of  water  or 
glycerine.  Tincture  of  iodine,  wine,  and  other  irritating  and  astringent 
solutions  may  be  employed.  The  quantity  should  vary  from  twenty 
minims  to  a  fluidrachni,  according  to  the  size  of  the  tumor,  and  should  be 
left  within  the  cyst  cavity. 

Cysts  with  thick  cheesy  contents,  if  not  excised,  should  be  split  open. 
The  surgeon  must  then  scrape  out  the  contents,  and,  if  he  does  not  re- 
move the  cyst  wall,  he  must  mop  the  interior  of  the  sac  with  strong  car- 
bolic acid  or  some  strong  astringent  or  cauterizing  application,  and 
leave  the  wound  open  to  granulate.  This  destroys  the  secreting  surface 
of  the  wall  and  sets  up  inflammation,  which,  by  means  of  the  granulating 
process,  causes  the  wound  to  heal  and  the  cyst  to  become  obliterated. 


CHAPTER   YTII. 

WOUNDS   AND   SHOCK. 

Definition. — A  wound  is  a  sudden  and  recent  solution  of  continuity 
of  the  soft  parts  caused  by  mechanical  violence.  A  solution  of  continuity 
of  such  tissue  produced  sloivly  by  mechanical  pressure  or  violence,  or  by 
inflammation  idiopathically,  is  an  ulcer ;  a  solution  of  continuity  of  bone 
is  called  a  fracture ;  hence,  the  term  wound  gives  the  idea  of  sudden  vio- 
lence to  the  soft  tissues  of  the  body.  This  mechanical  violence  is  usually 
directed  from  without,  but  it  may  arise  from  within,  as  is  the  case  when 
wounds  are  produced  by  muscular  efforts  or  by  the  projection  of  frag- 
ments of  bone  in  fractures. 

Varieties. — Wounds  are  either  freely  exposed  to  the  external  air 
when  they  are  called  open  wounds,  or  are  protected  from  such  exposure 
by  the  more  or  less  perfect  integrity  of  the  skin,  when  the  term  sub- 
cutaneous is  applied.  A  wound  communicating  with  the  air  by  a  small 
cutaneous  opening  may  still  be  considered  a  subcutaneous  wound,  as  are 
also  wounds  beneath  the  mucous  membranes,  though  the  term,  in  this 
instance,  is  a  misnomer. 

For  convenience  of  description  I  classify  wounds  under  four  heads : 
1.  Contused,  or  those  in  which  the  injury  consists  in  a  crushing  or  bruis- 
ing of  the  parts,  with  or  without  I'upture  of  the  integument.  2.  Incised, 
or  those  in  which  the  tissues  are  divided  cleanly,  or  cut,  as  by  a  sharp 
knife,  and  in  which  the  length  of  the  wound  greatly  exceeds  its  depth. 
3.  Punctured,  or  those  in  which  a  wound  is  made  by  a  pointed  instru- 
ment, and  in  which  the  depth  exceeds  the  length.  4.  Lacerated,  or  those 
in  which  the  structures  are  torn  apart,  giving,  therefore,  irregular  edges 
to  the  wound.  All  wounds  are  referable  to  one  of  these  groups,  though 
they  may  possess  additional  characteristics :  thus,  any  wound  infected 
Avith  a  specific  poison  becomes  a  poisoned  wound ;  if  the  vulnerating 
body  enters  a  cavity,  as  the  chest  or  a  joint,  a  penetrating  wound  results ; 
and  missiles  thrown  by  the  explosive  force  of  gunpowder  produce  con- 
tused or  lacerated  injuries,  called  gunshot  wounds. 

Symptoms. — Contused  wounds  are  produced  by  blows  or  by  sudden 
forcible  contact  with  surfaces  that  have  no  sharp  edges.  The  typical 
contused  wound  is  the  ordinary  bruise  or  contusion  in  which  there  is  no 
laceration  of  the  skin  ;  ordinarily,  however,  contused  wounds  are  lace- 
rated wounds  in  which  the  bruising  is  a  more  prominent  feature  than  the 
laceration.  I  consider  a  simple  bruise  or  contusion  a  contused  wound, 
because  there  is  a  solution  of  continuity  of  the  subcutaneous  tissues  in 
all  such  cases.  Contused  wounds  may  involve  the  skin  and  superficial 
fascia  only,  or  may  extend  also  to  the  muscles  and  deep  structures.  I 
have  seen  the  muscles  of  the  arm  so  pulpefied  that  amputation  was  re- 
quired, though  the  skin  appeared  scarcely  injured.  In  persons  with  a 
great  deal  of  subcutaneous  fat  a  slight  degree  of  pressure,  as  from  a 
pinch  with  the  fingers,  will  cause  a  distinct  bruise,  because  the  vessels  are 
so  readily  ruptured.     The  characteristics  of  this  class  of  wounds  are  dull 


114  SHOCK. 

pain  or  numbness,  a  black  and  blue  color  at  the  seat  of  injury  due  to 
extravasation  of  blood  from  the  ruptured  capillary  vessels,  some  swelling 
from  etilised  serum,  little  or  no  hemorrhage  from  any  accompanying 
laceration  of  the  skin  that  may  exist,  and  a  tendency,  if  the  contusion  be 
severe,  to  the  production  of  abscess  and  gangrene.  Abscess  and  gangrene 
result  because  a  place  of  least  resistance  is  produced  in  the  injured  tissues 
and  because  the  cellular  vitality  is  imjiaired,  thus  giving  opportunity  for 
bacterial  action. 

When  structures  are  divided  by  a  keen  instrument  and  the  length  of 
the  wound  is  a  more  consi)icuous  feature  than  its  depth  the  term  incision 
or  incised  wound  is  employed.  Incised  wounds  are  characterized  by 
acute  pain  and  hemorrhage,  a  tendency  to  retraction  or  gaping  of  the 
edges,  and  rapid  cicatrization.  These  features  vary,  of  course,  with  the 
locality  and  extent  of  the  injury.  The  bleeding  washes  away  bacteria 
and  tends  to  keep  the  wound  aseptic,  hence  the  rapid  healing  often  seen. 

Punctured  wounds  are  those  inflicted  by  a  pointed  instrument  piercing 
the  tissues,  and  hence  they  are  remarkable  for  depth  rather  than  for 
linear  extent.  A  wound  one  inch  long  and  a  half  inch  deep  made  by  a 
knife  is  an  incised  wound  ;  one  of  similar  extent,  but  three  inches  deep,  is 
a  punctured  wound.  Punctured  wounds  vary  according  as  they  are 
made  with  dull  or  sharp  pointed  instruments;  in  the  former  case  they 
resemble  lacerations,  in  the  latter  incisions.  As  a  rule,  however,  it  may 
be  said  that  punctures  are  aceoni))anied  by  great  pain  and  slight  hemor- 
rhage. They  are  especially  liable  to  be  followed  by  severe  inflammation, 
because  they  are  not  likely  to  be  kept  as  free  from  bacteria  as  are  those 
wounds  which  bleed  profusely  and  which  are  readily  cleansed. 

Wounds  produced  by  disruption  or  tearing  asunder  of  the  tissues  are 
termed  lacerations  or  lacerated  wounds,  and  are  frequently  accompanied 
by  contusion  of  the  parts.  In  fact,  a  force  which  causes  crushing  of  the 
tissues  without  much  tearing  of  the  integument,  gives  rise  to  a  contused 
wound,  while  the  same  force,  so  applied  as  freely  to  rupture  the  skin  as 
well  as  underlying  structures,  is  said  to  cause  a  laceration.  Lacerations 
are  distinguished  by  irregular  jagged  edges,  moderate  pain,  slight  hemor- 
rhage, little  gaping,  a  tendency  to  suppuration  and  sloughing  of  the 
edges  and  slow  cicatrization.  These  features  depend  upon  the  method  of 
injury,  for  it  is  the  tearing  and  twisting  of  the  vessels  and  nerves  that 
prevent  bleeding  and  acute  pain,  and  the  devitalization  and  irregularity 
of  the  torn  edges  that  occasion  sloughing,  favor  microbic  infection,  and 
prevent  rapid  healing. 

Shock. 

Definition. — The  constitutional  symptoms  that  immediatehj  ^oWow  the 
receipt  of  a  wound  or  injury,  if  it  be  sufficient  to  induce  general  dis- 
turbance, are  grouped  under  the  head  of  shock  or  collapse.  Subsequently 
the  general  symptoms  pertaining  to  inflammation  arise,  if  the  lesion  is 
grave  enough  to  cause  an  active  process  of  this  kind.  Delayed  shock  I 
believe  to  be  impossible.  Cases  so  named  are  doubtless  instances  of  fat 
embolism,  saprtemia,  septiciemia,  or  other  imperfectly  understood  con- 
ditions.* 

Symptoms. — Slight  shock  is  shown  by  pallor  of  the  skin,  a  sense  of 
giddiness  and  nausea,  and  a  feeling  of  approaching  unconsciousness.  This 
is  but  temporary,  and  reaction  or  return  to  the  physiological  condition 

1  For  a  resume  of  this  subject  see  article  on  Collapse  in  Holmes's  System  of  Surgery, 
American  edition,  Phila..  18S1. 


TEE  ATM  EXT.  115 

quickly  occurs.  When  severe  shock  is  preseut  there  is  great  depression 
exhibited  by  muscular  relaxation,  pallid  and  shrunken  features,  a  lan- 
guid and  bewildered  expression,  clammy  sweating,  a  frequent  and  per- 
haps intermittent  jjulse  which  sometimes  it  is  said  may  be  slow,  shallow 
and  gasping  respiration,  a  lowered  bodily  temperature  Varying  from  one- 
third  of  a  degree  to  two  or  three  degi-ees  below  normal,  and  uausea  and 
vomiting. 

Usually  the  mind  is  clear  or  at  most  only  slightly  affected  by  aberra- 
tions of  the  special  senses.  The  tranquil  mental  condition  of  patients 
suffering  from  profound  shock  due  to  grave  railroad  mutilations  is  often 
very  distressing  to  the  observer.  If  these  symptoms  of  shock  continue 
the  patient  dies,  usually  before  inflammatory  processes  begin  at  the  seat 
of  injury,  from  cardiac  failure. 

In  sudden  death  the  heart  may  be  spasmodically  contracted,  but  oftener 
perhaps,  the  right  cavities  and  venous  trunks  are  engorged  with  blood. 

Eecovery  from  shock  takes  place  by  the  depression  stage  being  fol- 
lowed by  reaction,  which  is  evidenced  by  increasing  power  and  slowino- 
of  the  pulse,  by  a  healthier  hue  of  skin,  a  rise  in  temperature,  and  a  dis'- 
position  on  the  part  of  the  patient  to  change  his  posture.  Eeactiou  mav 
be  inordinate  and  pass  across  the  health  line  to  the  domain  of  constitu- 
tional over-action  when  symptoms  akin  to  asthenic  inflammatory  fever 
occur.  It  is  usually  preferable,  however,  to  have  an  excess  ratheV  than 
a  deficiency  of  reaction,  since  it  is  easier  to  control  force  than  to  create 
it ;  but  the  condition  of  excitability,  coupled  with  prostration,  must  not 
be  mistaken  for  excessive  reaction.  The  time  at  which  reaction  occurs 
depends  on  the  nature  of  the  injury  and  the  recuperative  force  of  the 
individual,  and  varies  from  minutes  to  hours. 

The  degree  of  shock  varies  with  the  severity  of  the  injurv  and  the 
impressibility  of  the  patient.  The  greater  the  extent  of  the  injury  and 
themore  important  the  structures  involved,  the  more  profound  in  a  given 
patient  will  be  the  shock.  On  the  other  hand,  however,  we  find  that  an 
impressible_  person  will  show  great  shock  upon  the  receipt  of  a  trivial 
wound,  while  a  much  more  serious  lesion  in  another  man  will  be  accom- 
panied by  little  shock. 

Shock  is  greater  in  injuries  of  the  trunk  than  of  the  extremities,  and 
in  wounds  of  the  abdomen  than  in  those  of  the  chest.  In  estimating  the 
degree  of  shock  and  in  diagnosticating  the  condition  itself  the  surgeon 
must  remember  that  direct  injury  to  nerve  centres,  hemorrhage,  fat 
embolism,  rapid  septicaemia,  and  abstraction  of  heat  from  internal  viscera, 
and  fright  are  liable  to  simulate  or  increase  the  symptoms  of  shock.  The 
heart  and  kidneys  should  always  be  examined  prior  to  operations,  because 
chronic  disease  of  these  organs  increases  the  severity  of  the  shock  of 
operation. 

The  pathological  condition  causing  the  symptoms  termed  shock  lies  in 
the  sympathetic  nervous  system,  and  is  probably  a  paralysis  of  the  vaso- 
motor centres.  The  perturbation  of  the  vaso-motor  nerves  produces  a 
spasmodic  contraction  of  the  minute  bloodvessels,  and  then  lowered  tem- 
perature, pallor  and  the  concomitant  symptoms  are  exhibited. 

Treatmext. — The  treatment  of  shock  will  be  discussed  here,  because 
in  severe  injuries  the  surgeon's  attention  is  du-ected  to  this  condition 
before  local  measures  for  the  cure  of  the  wound  are  adopted.  I  shall 
then  recur  to  the  subject  of  wounds  and  consider  the  modes  of  healing 
and  the  treatment  of  the  different  classes  of  wounds. 

If  the  symptoms  are  slight  a  drink  of  water  and  fanning  the  face  are 


116  SHOCK. 

sufficient  treatment.  In  severe  shock  perfect  quiet  of  mind  and  body  in 
the  recumbent  })osition  and  heat  to  keep  up  the  bodily  tein])erature  are 
the  most  imj)()rtant  rc(juisites.  Cardiac  stinnihints  and  food  arc  then 
demanded  in  the  majority  of  cases.  Venesection,  recommended  by  some 
authors  because  of  the  occasional  engorgement  of  the  veins  and  right 
heart,  is  probably  never  recpiired.  The  distention  of  the  hollow  organs 
occurs  from  the  vaso-motor  nervous  disturbance  causing  paralysis  and  is  a 
result,  not  a  cause  of  the  shock.  Heat  and  artificial  respiration  will  be 
well  calculated  to  distribute  the  blood  engorging  the  viscera.  Heat  is  to 
be  maintained  by  warm  rooms,  blankets,  bottles,  or  rubber  bags  filled  with 
hot  w'ater,  hot  water  enemas,  or  by  the  hot  bath  in  which  the  temperature 
is  raised  from  98°  to  110°  F.  A  small  amount  (f^  ss-t^  ij)  of  stimulant 
in  the  form  of  brandy  or  whiskey,  may  be  administered  ;  but  it  should  be 
remembered  that  many  injured  persons  have  been  given  alcoholic  stimulus 
by  the  bystanders  before  the  surgeon's  arrival,  or  have  taken  it  as  a  bever- 
age before  the  accident.  Overdosing  with  such  remedies  produces  de- 
pression. Hence,  the  amount  spoken  of  above  should  seldom  be  increased 
but  may  sometimes  be  repeated  at  the  expiration  of  several  hours.  Small 
amounts  of  cofiee,  beef-tea,  or  milk  also  should  he  given  at  intervals,  but 
here,  as  in  the  case  of  alcohol,  large  amounts  lying  unabsorbed  in  the 
stomach  do  harm  and  may  induce  vomiting. 

The  pulse  is  the  indication  to  guide  the  attendant.  If  it  increases  in 
force  and  diminishes  in  rapidity  reaction  has  begun.  Time  is  then  re- 
quired ;  reaction  from  severe  shock  may  extend  over  six,  twelve,  or 
twenty- four  hours.  The  drugs  employed  in  the  management  of  shock  are 
morphia  (gr.  l—]),  tincture  of  digitalis  (tt\^  xx-f^  j),  carbonate  of  ammo- 
nium (gr.  v-xx),  atropia  (gr.  -bV^uV)'  ^^^  ^^  which  can  be  given  hypoder- 
matically;  and  quinia  (gr.  v-xx),  best  given  by  the  mouth  or  rectum. 
Ether  in  half-drachm  doses  may  be  given  subcutaneously.  I  have 
obtained  in  profound  and  almost  hopeless  shock  very  gratifying  results, 
which  I  believe  due  to  the  hy])odermatic  adniinistration  of  digitalis,  ammo- 
nia, and  alcohol. 

As  soon  as  reaction  is  fairly  established  cardiac  stimulants  must  be 
stopped  lest  the  traumatic  or  inflammatory  fever  be  enhanced. 

When  operations  are  necessary  after  injuries  inducing  severe  shock,  the 
surgeon  should  wait,  as  a  rule,  until  reaction  has  begun,  since  there  is  then 
less  danger  of  causing  dangerous  depression  from  the  shock  of  operation. 
Etherization  has  usually  a  stimulating  effect  and  seems  to  combat  the 
symptoms  of  shock. 

The  shock  after  operations  is  often  excessive  because  the  surgeon  has 
been  too  slow  in  his  operative  work,  has  exposed  the  patient  to  cold  air, 
has  reduced  his  temperature  by  wet  dressings  and  irrigation,  or  has  de- 
pressed him  by  prolonged  amesthesia. 


CHAPTEK    IX. 

MODE  OF  REPAIR  AND  TREATMENT  OF  WOUNDS. 

Repair  of  Wounds. — All  wounds,  large  or  small,  open  or  cutaneous, 
incised  or  punctured,  contused  or  lacerated,  heal  by  that  reparative  pro- 
cess which  I  have,  in  the  first  chapter,  called  inflammation.  In  other  words, 
what  was  there  styled  inflammation  is  really  nature's  reparative  effort  to 
reconstruct  the  injured  tissues  and  limit  the  injurious  influence  of  the  origi- 
nal irritant.  The  processes  called  inflammation  are  efibrts,  often  more  or 
less  futile,  to  restore  physiological  conditions.  Inflammation  is  not  a  dis- 
ease. 

When  the  wound  is  of  such  a  character  that  accurate  adjustment  of  the 
several  tissues  can  be  and  is  accomplished,  a  reparative  effort  merely  sufii- 
cient  to  supply  a  small  amount  of  fibrine  or  lymph  supervenes.  This 
fibrine  glues  the  parts  together,  then  becomes  changed  into  granulation 
tissue,  and  finally  into  connective  tissue,  or  scar,  analogous  to  the  original 
structures.  Thus  is  repaired  the  breach  of  continuity.  This  method  of 
union  is  union  by  first  intention,  or  fibrinous  repair,  and  occurs  when  no 
foreign  body,  clotted  blood  or  undue  amount  of  transudation  prevents 
accurate  approximation,  and  when  the  parts  are  kept  quiet  and  the 
patient's  tissues  are  in  a  healthy  condition  and  free  from  microbic  infec- 
tion or  other  irritation.  By  this  mode  are  repaired  subcutaneous  and 
other  aseptic  wounds. 

When  there  is  a  loss  of  substance,  or  an  irregularity  of  the  edges  of 
the  wound,  the  space  or  chasm  due  to  the  injury  or  to  the  destruction  of 
the  ragged  edges  by  sloughing  is  gradually  covered  and  more  or  less  filled 
up  with  minute  granular  bodies  of  a  pink  color  called  granulations. 
These  are  formed  from  lymph,  capillary  loops  and  indifferent  cells  in  the 
same  way  as  the  uniting  band  in  cases  of  union  by  first  intention.  If 
the  wound  is  kept  aseptic  there  will  be  no  suppuration  and  epithelial 
formation  will  occur  when  the  granulation  tissue  has  filled  up  or  nearly 
filled  up  the  cavity.  In  the  meantime  there  will  be  a  serous  exudate  from 
the  surface  of  the  granulations.  It  is  difficult  to  keep  pyogenic  organisms 
away  from  such  wounds  when  large  and  superficial  suppuration  is  not 
unusual.     Absolute  asepsis  should  be  attempted  always. 

The  granulations  have  absorbent  power  and  are  gradually  converted 
into  a  bluish-white  connective  tissue,  called  the  cicatrix,  which  occupies 
the  situation  of  the  wound  and  assumes  characteristics  similar,  though  not 
identical,  with  the  structures  injured.  This  method  is  union  by  second 
intention  or  granulation.  It  is  the  only  means  by  which  healing  of 
wounds  can  occur  if  union  by  first  intention  fails  to  take  place.  It  is  apt 
to  occur  in  contused  and  lacerated  wounds  unless  they  are  subcutaneous 
or  have  their  devitalized  edges  trimmed  off,  are  rendered  aseptic  and 
accurately  approximated.  Other  varieties  of  healing  have  been  described, 
but  they  are  but  modifications  of  the  two  here  considered,  which  them- 
selves are  identical  in  pathological  significance  and  process. 

Healing  by  first  intention  is  much  to  be  preferred,  because  it  requires 


118      MODE    OF    REPAIR    AND    TREATMENT    OF    WOUNDS. 

much  less  time,  say  from  two  to  seven  days,  and  leaves  very  little  cica- 
trix. I'nion  by  granulation,  or  second  intention,  requires  weeks  or 
months,  according  to  the  size  of  wound  or  ulcer,  and  leaves  a  large  scar, 
which  olten  gives  rise  to  deformity,  on  account  of  the  contractile  tendency 
of  cicatricial  tissue. 

Treatment  of  Woixds. — In  the  management  of  all  wounds,  there  are 
four  cardinal  rules  :  1.  Arrest  hemorrhage.  2.  Render  the  wound  asep- 
tic by  removal  of  all  dirt  and  foreign  bodies,  as  fiir  as  it  is  possible  to  do 
so  without  incurring  risk.  8.  Bring  the  parts  into  apposition,  if  the 
attempt  does  not,  and  will  not,  cause  pressure  and  tension.  4  Assist  the 
natural  reparative  process  by  mechanical  rest  and  the  prevention  of 
putrefaction  and  su])])uration. 

These  precepts  apply  to  every  wound,  hut  their  relative  importance 
varies  with  the  character  of  the  injury.  Thus,  in  incised  wounds  there 
is  often  much  bleeding  to  be  arrested,  but  no  foreign  body  to  be  removed, 
while  in  contused  and  lacerated  injuries  there  is  frequently  no  hemorrhage, 
but  numerous  particles  of  foreign  materials,  such  as  shot,  shreds  of 
clothing  and  dirt,  to  be  extracted. 

The  arrest  of  bleeding  will  be  spoken  of  under  Diseases  of  the  Blood- 
vessels, and  the  methods  of  approximating  and  dressing  wounds,  and  of 
preventing  germ  infection  under  Minor  Surgery  and  Surgical  Dressings. 
Hence,  I  shall  at  this  point  speak  only  of  the  constitutional  treatment 
required  by  patients  suffering  from  wounds.  To  cooperate  with  the  processes 
of  repair  and  to  prevent  the  occurrence  of  retarding  complications  may  or 
may  not  require  the  surgeon's  interference.  In  aseptic  wounds,  union 
usually  occurs  steadily  and  expeditiously,  and  nothing  is  required  but 
patience  on  the  part  of  the  attendant,  who  has  dressed  the  wound  with  germ- 
free  applications.  At  other  times,  because  of  the  contaminated  nature  of 
the  wound  or  because  of  the  conditions  or  surroundings  of  the  patient, 
sloughing,  burrowing  of  pus,  abscesses,  erysipelas,  or  pysemia,  render  the 
surgeon's  duties  responsible  in  the  highest  degree.  As  all  wounds  heal  by 
the  reparative  efforts  of  nature,  inaccurately  called  inflammation,  the 
treatment  detailed  on  previous  pages,  for  the  management  of  the  inflam- 
matory process  is  to  be  pursued.  Hence  patients  showing  a  sthenic 
form  of  constitutional  implication  must  be  depleted  and  depressed  by 
bloodletting,  purging,  arterial  sedatives,  and  other  measures  of  a  kindred 
nature.  The  asthenic  type,  on  the  other  hand,  demands  supportive  treat- 
ment, which  is  effected  by  tonics,  stimulants,  and  a  generous  nutritious  diet. 

Wounds  must  be  treated  locally  according  to  their  special  characters, 
after  the  general  rules  given  above  have  been  followed ;  but,  in  all  cases, 
the  most  rigid  asepsis  or  antisepsis  must  be  carried  out.  There  is  no 
doubt  that  serious  complications  arising  in  connection  with  wounds, 
whether  the  wounds  be  accidental  or  operative,  can  be  mostly,  if  not 
entirely,  avoided  by  keeping  the  wound-surfaces  free  from  micro/irganisms. 
It  is  to  these  organisms,  either  introduced  at  the  time  of  injury  or  allowed 
to  come  in  contact  with  the  wound  at  a  later  period,  that  the  constitutional 
disturbances,  slow  healing,  and  suppuration  so  often  found,  are  due.  It 
is  the  surgeon's  duty  to  avoid  such  microbic  infection  in  operation  wounds, 
and  to  limit  it  in  accidental  wounds  when  it  has  taken  place  before  he 
had  control  of  the  patient's  destiny.  Death  is  often,  and  has  often  been, 
due  to  the  surgeon's  ignorance  or  neglect  of  these  precautions.  This  sub- 
ject will  be  further  discussed,  under  Surgical  Dressings,  in  the  next 
section. 

Treatment  of  the  Different  Classes  of  Wounds. — Contusions,  being  subcu- 


TREATMENT    OF    WOUNDS.  119 

taneous  wounds,  require  little  treatment.  If  there  is  a  great  deal  of  sub- 
cutaneous extravasation,  cold  water  and  pressure  with  a  bandage  are 
indicated  to  stop  the  hemorrhage.  Absorption  of  the  effused  blood  takes 
place  very  slowly,  but  gradually  the  black  and  blue  appearance  changes 
to  a  greenish  and  yellowish  hue,  and  the  discoloration  then  disappears. 
Alcohol,  chloride  of  ammonium  solution  (gr.  x-xx  to  the  fluidounce), 
tincture  of  arnica  and  hot  water  are  often  used  as  external  lotions,  but  the 
benefit  derived  from  them  is  doubtful.  They  do  no  harm,  however,  and 
serve  to  satisfy  the  patient.  Moreover,  the  rubbing  which  they  encourage 
probably  assists  the  vessels  in  taking  up  the  effused  blood.  If  the  extra- 
vasation is  very  great  in  regions  where  loose  connective  tissue  is  abund- 
ant, as  in  the  eyelids  and  scrotum,  the  swelliug  will  be  so  great  that  the 
surgeon  may  be  tempted  to  make  incisions  for  its  escape.  This  is  usually 
bad  practice,  because  large  amounts  of  blood  thus  effused  will  be  absorbed, 
while  contact  with  the  air  renders  access  of  pyogenic  or  putrefactive 
bacteria  probable.  When  extravasation  of  blood  and  rapid  inflammatory 
effusion  of  serum  cause  such  swelling  and  tension  that  the  limb  becomes 
cold  and  there  is  danger  of  gangrene  from  interstitial  pressure,  long  incis- 
sions  imist  be  made  through  the  tense  skin.  The  skin  then  retracts  and 
relieves  the  pressure.  These  incisions  must  be  made  with  antiseptic  pre- 
cautions, and  the  whole  limb  dressed  with  gauze.  When  absorption  does 
not  occur,  but  there  remains  a  tumor  filled  with  fluid  blood  for  a  long 
time,  the  term  hsematoma  is  employed.  This  usually  requires  aspiration 
or  incision.  Abscesses  and  serous  cysts  occurring  subsequent  to  contu- 
sions demand  evacuation. 

The  treatment  of  open  contused  wounds  and  of  lacerations  may  be  con- 
sidered together,  because  the  same  principles  govern  their  surgical  manage- 
ment. Such  wounds  are  nearly  always  infected  with  germs,  from  con- 
tact with  the  vulnerating  body  or  from  their  surroundings  at  the  time  of 
their  infliction.  Before  the  wounds  are  dressed,  it  is  very  necessary  to 
render  them  aseptic.  This  is  done  by  the  removal  of  all  particles  of  dirt 
with  aseptic  forceps  or  fingers,  and  by  cleaning  and  disinfecting  the 
.  wounds  by  means  of  irrigation  with  antiseptic  solutions.  Corrosive  subli- 
mate solution  (1  :  500  or  1  :  1000),  poured  upon  and  into  the  wound 
from  a  pitcher  or  a  syringe  or  squeezed  from  a  sponge,  is  one  of  the  most 
eflfective  of  such  agents.  Betanaphthol  and  other  substances  may  be 
employed.  All  accidental  wounds  must  be  thoroughly  sterilized  in  this 
manner  in  order  to  avoid  the  occurrence  of  suppuration.  In  large 
wounds  where  such  a  procedure  would  give  pain,  it  is  not  only  justifiable, 
but  it  is  requisite,  to  give  ether  in  order  that  this  important  procedure 
may  not  be  omitted.  It  is  good  surgery,  after  having  etherized  the 
patient,  to  scrape  and  scrub  such  wounds  thoroughly  with  a  nail-brush 
and  soap-suds  before  using  the  antiseptic  solution.  This  double  proceed- 
ing removes  or  destroys  all  germs  that  may  exist  in  the  wound.  Injuries 
received  from  machinery  almost  always  need  such  treatment,  because  of 
the  dirt  and  grease  ground  into  the  tissues  at  the  time  of  the  accident,  or 
upon  the  patient's  skm  before  the  receipt  of  injury.  After  such  wounds 
have  been  made  germ-free,  they  should  be  sutured  as  operative  wounds, 
and  provision  made  by  catgut  strands  or  drainage-tubes  for  the  escape 
of  serous  and  other  fluids  which  may  exude.  The  conversion  of  such  acci- 
dental wounds  into  aseptic  wounds  by  these  measures  is  an  essential  first 
step  in  treatment.  Wounds  subjected  thoroughly  to  this  treatment 
usually  unite  by  first  intention.  If  this  is  not  the  case  the  granula- 
tion process  goes  on  so  rapidly  that  the  patient's  convalescence  is  com- 


120      MODE    OF    REPAIR   AND    TREATMENT    OF    WOUNDS. 

paratively  short.  In  former  times  it  was  considered  impossii)le  for  such 
wounds  to  heal  without  suppuration,  which  was  accompanied  in  many 
instances  by  more  or  less  violent  constitutional  implication.  We  now 
know  that  the  wounds  were,  in  those  days,  really  complicated  by  infec- 
tion from  pyogenic  and  putrefactive  germs. 

After  thorough  cleansing  with  sublimate  or  betanaphthol  solution, 
and  after  all  foreign  bodies  have  been  jiicked  out  with  sterilized  forceps, 
the  bruised  and  lacerated  parts  should  be  adjusted  and  kc])!  in  j)lace  by 
sutures,  if  this  can  be  done  without  causing  tension  or  interfering  with 
the  escape  of  the  fluids  to  be  subsetpiently  secreted.  ]\Iuch  damage  is 
often  done  by  making  nice  approximation  of  such  wounds  and  jirovidiug 
no  escape  by  drainage-tubes  and  counter  oj)enings  for  the  serum  and  pus 
which  may  arise  in  a  few  hours  and  cause  tension  and  pain.  If  the  fluids 
thus  secreted  find  no  free  avenue  of  escape,  burrowing  of  pus  and  septic 
conditions  are  liable  to  occur.  Parts  that  cannot  readily  be  brought 
together  should  be  allowed  to  gape. 

Union  by  granulation  is  the  method  of  healing  in  these  w"ounds.  Con- 
tused and  lacerated  wounds  are  usually  followed  by  sloughing  of  their 
ragged  borders  ;  but  it  is  improper  to  cut  away  anything  more  than  the 
edges  at^the  hrst  dressing,  since  it  is  not  })ossible  to  determine  what  parts 
are  actually  devitalized.  The  ordinary  gauze  dressing  should  l)c  used. 
Thorough  drainage  of  deep  and  irregular  W()unds  by  tubes,  strings  of 
rubber,  or  horsehair,  is  important.  When  the  sloughing  stage  has  given 
place  to  the  granulation  stage  the  resulting  ulcerated  surface  is  treated  as 
an  ulcer.  If  abscesses  are  liable  to  form,  provision  must  be  made  for 
draining  the  deep  parts  by  drainage-tubes,  incisions,  and  washing  out 
with  syringes  or  by  hydrostatic  pressure. 

When  the  injury  has  caused  complete  devitalization,  amputation  must 
be  done  as  soon  as  reaction  from  shock  has  occurred.  If  the  soft  parts 
are  completely  stripped  from  the  bones  amj)utation  may  be  demanded, 
even  when  the  osseous  tissues  are  intact,  because  of  the  danger  of  acute 
traumatic  gangrene.  If  attempts  have  been  made  to  preserve  crushed 
limbs  and  rapiflly  spreading  gangrene  supervenes,  amputation  is  usually 
to  be  done  promptly  at  a  high  point  of  the  limb. 

In  incised  wounds  an  attempt  should  always  be  made  to  secure  union 
by  first  intention,  becau.^^e  thus  time  is  saved,  the  scar  is  less  disfiguring, 
there  is  no  drain  from  the  system  as  when  suppuration  occurs,  and  there 
is  less  chance  for  septic  complications.  If  the  effort  fails  union  occurs  by 
granulation,  as  in  lacerated  wounds.  In  lacerated  and  contu.sed  wounds 
union  by  first  intention  is,  from  the  nature  of  the  injury,  almost  imj)ossi- 
ble.  After  arrest  of  hemorrhage,  removal  of  foreign  matters,  and  the 
production  of  an  aseptic  condition  in  incised  wounds,  accurate  adjustment 
is  to  be  obtained  by  sutures  of  catgut,  silk,  or  wire;  or  in  small  wounds 
by  a  layer  of  gauze  or  absorbent  cotton  glued  to  the  skin  by  collodion. 
About  the  face  the  latter  dressing  is  sometimes  preferable  because  a 
scar  is  left  by  sutures.  The  transparent  gauze  allows  the  surgeon  to  see 
that  the  wound  is  evenly  apposed,  and  any  unex])ected  serous  or  purulent 
discharge  soon  leaks  through  the  meshes  of  the  tarletan  and  is  not  shut 
in  by  the  dressing.  In  other  places  than  the  face  I  prefer  sutures,  because 
even  deep  wounds  can  be  apposed  along  their  entire  surfaces  by  buried 
catgut  sutures  applied  to  each  successive  layer  of  tissue.  There  is  no  ob- 
jection to  the  minute  points  of  scarring  from  sutures  except  on  the  face. 
I  always  use  sutures  for  the  scalp.  The  application  of  interrupted  and 
twisted  sutures  and  of  the  collodion  gauze  dres.sing  will  be  described  in 


TREATMENT    OF    WOUNDS.  121 

the  chapter  on  Minor  Surgery.  I  will  merely  repeat  at  this  point  the 
caution  to  students  that  there  is  a  tendency  to  apply  sutures  too  tightly. 
Mere  approximation  of  the  edges  of  the  wound  is  what  is  desired.  Any 
marked  puckering  is  a  serious  fault.  Catgut  sutures  stretch  a  little  after 
tying  and  can  be  drawn  tighter  than  wire  ones. 

Punctured  wounds  when  made  with  a  sharp  instrument  require  treat- 
ment like  incised  wounds;  when  made  with  dull  instruments,  such  as  car- 
penter's nails,  they  are  practically  lacerations.  If  they  are  penetrating 
wounds  there  will  probably  arise  inflammation  of  the  lining  membrane  or 
viscera  of  the  cavity  opened.  This  will  demand  treatment  directed  to 
the  special  lesion.  The  removal  of  the  foreign  body  is  often  difficult  in 
the  case  of  punctures.  If  withdrawal  with  forceps  is  impossible  a  free 
incision  will  be  required,  especially  if  the  vulnerating  body  is  buried  in 
the  tissues  and  invisible.  This  should  usually  be  done  at  once,  and  par- 
ticularly when  the  foreign  body  was  probably  covered  with  dirt  and  is 
especially  liable  to  cause  septic  infection.  The  incision  adds  little  or  noth- 
ing to  the  gravity  of  the  injury,  may  result  in  detection  of  the  foreign 
body,  and  even  if  unavailing  gives  free  drainage  and  lessens  the  dangers 
of  erysipelas  and  other  complications  frequent  in  punctured  wounds.  A 
simple  or  an  electromagnet  has  been  found  serviceable  at  times  in  re- 
moving chips  of  iron  after  lacerations  or  punctures  of  the  eyeball.  It  is 
almost  impossible  to  render  a  punctured  wound  aseptic  without  enlarging 
it ;  hence  it  is  often  good  policy  to  increase  it  in  order  to  sterilize  it  and 
prevent  the  occurrence  of  cellulitis  or  gangrene. 

Poisoned  Wounds  are  usually  punctures,  since  stings  of  insects,  fangs 
of  reptiles,  and  points  of  knives  are  usually  the  vulnerating  instruments. 
Any  form  of  abrasion  or  wound  of  the  skin  may  be  inoculated,  however, 
and  at  times  simple  maceration  of  the  skin  with  poisonous  fluids  in  loca- 
tions where  the  integument  is  thin  is  sufficient. 

The  wounds  made  by  insects  are  comparatively  unimportant  in  this 
country.  It  need  only  be  said  that  if  the  sting  remains  in  the  w^ound  it 
should  be  extracted,  and  lead  water,  sublimate  solution  (1  :  1000),  water 
of  ammonia,  or  spirit  of  camphor  applied.  Bites  from  insects  with 
poisonous  saliva  should  be  managed  in  the  same  way.  Any  subsequent 
inflammation  should  be  treated  on  general  principles. 

Venomous  snake-bites  are  usually  accompanied  by  rapid  and  multiple 
interstitial  hemorrhage,  caused  by  an  interference  with  the  coagulability 
of  the  blood  and  disintegration  of  the  vessel  walls,  due  to  the  poison  ; 
paralysis  of  respiration  and  the  spinal  centres  ;  and  locally  great  swelling 
and  vesication.  The  profound  prostration  or  collapse  is  accompanied, 
however,  with  unimpaired  intellection.  Death  occurs  in  an  hour  or  so  if 
the  amount  of  poison  is  large,  but  in  other  cases  may  be  delayed  several 
days  and  occur  through  the  depressing  influences  of  gangrene  and  sup- 
puration. Many  constitutional  remedies  have  been  vaunted,  but  there  is 
no  positive  evidence  in  favor  of  any  except  alcohol,  which  should  be 
given  freely,  but  not  indiscriminately.  The  intravenous  injection  of  am- 
monia has  been  recommended,  but  its  value  is  not  yet  established.  The 
local  treatment  is  important,  and  consists  in  immediate  free  excision  of  the 
wound  and  surrounding  tissues,  the  application  of  a  tight  ligature  to  the 
limb  above  the  wound  to  prevent  venous  and  lymphatic  absorption, 
sucking  or  cupping  the  wound  left  by  the  knife  to  extract  the  poison, 
and  cauterization  with  equal  parts  of  carbolic  acid  and  alcohol. 

Permanganate  of  potash  freely  injected  into  the  wound  and  surround- 
ing tissues  is  serviceable  in  destroying  the  poison  and  should  always  be 


122      MODE    OF    REPAIR    AND    TREATMENT    OF    WOUNDS. 

used  if  obtainable.  Nitrate  of  silver  is  valueless  as  a  caustic,  as,  iudeed, 
it  always  is  when  a  tissue-destroyer  is  desired.  The  so-called  interniit- 
tent  ligature  is  a  rational  measure.  It  is  merely  a  tightly  constricting 
band,  applied  at  the  cardiac  side  of  the  wound  and  relaxed  momentarily 
at  intervals  in  order  to  allow  the  jtoison  to  enter  the  general  circulation 
slowly  and  in  divided  amounts.  This  gives  the  surgeon  a  better  oppor- 
tunity to  counteract  the  effects  of  the  poison  and  obtain  its  elimination 
than  when  the  venomous  material  is  suddenly  absorbed  in  full  amount. 
The  poison  is  a  chemical,  not  a  microbic,  one.  It  contains,  according  to 
Mitchell  and  Reichert,  two  albuminous  poisons,  called  by  them  venom 
peptone  and  venom  globulin.  With  the  venom  are  introduced  into  the 
wound  many  bacteria,  which  are  the  agents  and  causes  of  the  putrefac- 
tion which  so  rapidly  occurs  after  snake-bites. 

Inoculation  with  the  fluids  of  diseased  or  of  decomposing  animal  tissue 
at  times  causes  serious  poisoned  wounds.  Malignant  pustule,  or  charbou, 
contracted  from  cattle  suffering  with  murrain,  and  glanders,  or  equina 
due  to  inoculation  or  infection  from  horses  having  this  affection,  are  the 
most  important  forms  derived  from  the  lower  animals.  These  affections 
are  due  to  microorganisms  and  the  ptomaines  developed  by  their  growth. 
I  omit  the  di.scussion  of  hydrophobia  here,  because  all  pathologists  are  not 
agreed  a^  to  its  being  due  to  inoculation.  It  will  be  considered  under 
Diseases  of  the  Nervous  System. 

Malignant  pustule  is  especially  found  in  tanners  and  butchers  and  is 
characterized  by  a  vesicle  at  the  point  of  inoculation,  which  is  soon  fol- 
lowed by  violent  inflammatory  complications,  such  as  angeioleucitis,  cellu- 
litis, and  gangrene.  The  degree  of  asthenia  accompanying  this  car- 
buncular  inflammation  is  profound  and  shown  by  its  usual  symptoms. 
The  affection  is  due  to  the  presence  of  a  vegetable  organism,  the  anthrax 
bacillus,  contained  in  the  blood  and  other  fluids.  The  treatment  consists 
of  excision,  or  free  incision,  followed  by  thorough  cauterization  with  cor- 
rosive sublimate  or  carbolic  acid.  Saturating  the  cellular  tissues  with 
injections  of  iodine  has  been  considered  valuable.  Stimulant,  supportive, 
and  anodyne  remedies  internally  administered  are  required.  Free  in- 
cision through  the  swollen  and  infiltrated  ti.ssues  involved  are  indicated, 
even  after  the  early  stages. 

Glanders  is  another  infective  or  mycotic  disease,  and  is  characterized 
by  iisthenia  and  by  multiple  indurations  and  ulcers  of  the  surfiice,  in- 
flammation and  suppuration  of  the  salivary  glands,  and  profuse  nasal 
discharge ;  though  the  last  symptom  is  not  always  prominent  in  the  dis- 
ea.se  in  man.  The  treatment  should  be  conducted  on  general  principles, 
as  there  is  no  special  remedy  for  the  condition. 

The  prognosis  in  malignant  pustule  and  glanders  is  unfavorable  in  the 
majority  of  cases. 

The  term  dissection  wound  is  applied  to  injuries  received  during  opera- 
tions on  dead,  and  sometimes  on  living,  bodies.  They  occur  also  in 
butchers,  fish-dealers,  and  others  whose  occupation  causes  them  to  handle 
dead  animals.  Many  wounds  so  received  act  merely  as  similar  injuries 
inflicted  under  other  circumstances ;  sometimes  there  is  an  a<lditional 
amount  of  inflammation,  as  if  the  animal  fluids  irritated  the  part;  but 
occasionally  a  most  virulent  form  of  local  inflamniation  occurs,  and  is 
accompanied  by  grave  constitutional  symptoms  of  blood  infection. 
Persons  whose  previous  health  is  poor  suffer  more  frequently  from  such 
wounds  than  do  other  persons  whose  tissues  have  more  resistence  to  in- 
fectious influence-s.     These  disastrous  symptoms  appear  to  be  due  to  a 


TREATMENT    OF    WOUXDS.  123 

specific  poison  generated  in  the  cadaver  a  short  time  after  death,  or  per- 
haps before  death,  which  seems  to  be  destroyed  by  the  advent  of  marked 
decomposition.  Cases  of  death  from  peritonitis,  erysipelas,  and  pyaemia 
are  more  likely  than  others  to  cause  such  dissection  wounds.  These 
wounds  owe  their  virulence  to  microorganisms  or  the  chemical  products 
of  such  organisms.     They  are,  in  fact,  septic  wounds. 

There  is  a  complete,  or  almost  complete,  protection  afforded  by  pre- 
serving cadavers  with  zinc  chloride,  as  is  done  in  our  Philadelphia  dis- 
secting-rooms. It  is  important  to  recollect  that  the  poison  appears  at 
times  to  infect  the  pathologist,  who  is  making  an  autopsy,  through  the 
hair-follicles  and  unbroken  skin  of  the  hands,  especially  if  they  are  im- 
mersed in  the  fluids  of  py^emic  pleuritis  or  peritonitis. 

The  symptoms  of  a  dissection  wound,  it  of  the  ordinary  variety,  are 
those  of  an  acute  inflammation  about  a  wound — viz.,  pain,  swelling, 
inflamed  lymphatic  glands,  fever,  etc.  Quite  frequently  suppuration 
occurs.  In  the  more  serious  form  a  vesicle  appears,  after  the  lapse  of  a 
couple  of  days,  at  the  point  of  puncture,  and  is  followed  by  erysipelatous 
inflammation,  angeioleucitis,  rapid  involvement  of  the  cellular  tissue,  sup- 
puration, sloughing,  and  septic  symptoms,  as  shown  by  rigors,  fever, 
colliquative  sweating,  and  rapid  ])rostration  of  the  vital  powers.  Those 
cases  seem  to  be  worse  in  which  inflammation  of  the  lymphatic  glands 
occurs  before  active  inflammation  of  the  wound. 

The  treatment  consists  in  ligation  above  the  wound  to  prevent  absorp- 
tion, excision  and  cupping  to  get  rid  of  the  virus,  and  cauterization,  prob- 
ably best  effected  by  zinc  chloride,  corrosive  sublimate,  or  carbolic  acid. 
If,  however,  septic  symptoms  occur  in  spite  of  these  precautions,  quinia, 
alcoholic  stimulus,  anodynes,  nutritious  food,  and  supportive  agents  must 
be  given  and  the  wound  treated  by  incisions  and  antisejDtic  washes.  It 
s  said  that  the  spreading  inflammation  may  at  times  be  arrested  by  a 
blister  applied  around  the  limb,  above  the  wound,  as  soon  as  the  red  lines 
indicating  inflammation  of  the  lymphatic  vessels  appear.  Smearing  the 
surface  freely  with  mercurial  ointment  is  often  beneficial  in  these  and 
other  cases  of  angeioleucitis  and  phlebitis. 

Gunshot  Wounds. — Gunshot  wounds  are  injuries  produced  by  the 
explosive  force  of  gunpowder  confined  in  firearms.  They  may,  therefore, 
be  caused  by  the  powder  alone,  by  the  j^rojectiles  discharged,  by  pieces 
of  clothing  or  splinters  of  wood  given  motion  by  such  missiles,  and  by- 
portions  of  weapons  shattered  by  explosion.  Gunshot  wounds  partake  of 
the  nature  of  contused  and  lacerated  wounds,  and  hence  are  often  fol- 
lowed by  sloughing.  When  fractures  are  produced  they  are  almost  in- 
variably open,  or  compound  and  comminuted.  Cannon  balls  crush  and 
pulpefy  the  parts  struck.  The  wind  caused  by  a  passing  ball  does  not 
and  cannot  produce  a  contusion,  as  was  formerly  supposed.  In  injuries 
so  attributed  the  elastic  skin  has  escaped  injury,  though  actually  struck. 

The  wound  made  as  the  missile  enters  the  tissues  is  called  the  wound  of 
entrance,  that  made  as  it  leaves  the  part,  after  traversing  it,  is  termed  the 
wound  of  exit.  The  wounds  of  entrance  and  exit,  especially  if  made  by 
a  projectile  travelling  with  a  comparatively  moderate  velocity,  diflfer  in 
appearance.  The  former  is  small  and  has  depressed  and  regular  edges, 
stained,  perhaps,  with  grease  and  powder.  The  wound  of  exit  has  everted, 
ragged  margins,  not  stained,  and  is  much  larger  than  that  of  entrance, 
because  the  skin  has  no  external  support  when  it  receives  the  impact 
from  within.  Conicah  bullets  discharged  by  rifled  arms  travel  with 
such  velocity  that  these  distinctions  are  not  always  present. 


1-24       MODE     OF     REPAIR    AND    TREATMENT    OF     WOUNDS. 

A  bullet  may  traverse  the  tissues  in  a  direct  line,  be  cleHected  by  bones 
or  fascias,  or  be  split  against  a  bone  and  make  several  openings  of  exit. 
Instances  are  recorded  where  the  bullet  has  taken  a  circular  course  and 
been  found  imbedded  near  the  wound  of  entrance.  Portions  of  clothing 
or  wadding  carried  into  the  wound  act  as  complications.  Small  shot  fired 
at  short  range,  say  a  foot  or  two,  will  make  a  single  wound  of  entrance 
because  there  has  been  no  scattering.  Powder  alone  may,  if  discharged 
near  the  skin,  produce  a  serious  injury.  In  any  event,  if  unburnt  powder 
enters  the  skin  there  will  be  permanent  discoloration  like  tattooing, 
unless  the  grains  are  discharged  by  suppuration  or  removed  by  the 
surgeon. 

It  is  unnecessary  to  speak  here  of  shock,  hemorrhage,  and  the  other 
symptoms  of  gunshot  wounds,  since  they  correspond  with  injuries  of 
similar  gravity  produced  by  other  vulnerating  agents. 

The  treatment  consists  in  removing  the  foreign  body  as  soon  as  reaction 
is  established,  provided  it  can  be  done  without  seriously  increasing  the 
danger.  The  injury  has  been  produced  by  the  entrance  of  the  projectile, 
and  its  passive  residence  in  the  tissues  does  not  do  sufficient  harm  to  per- 
mit great  risks  to  be  taken  for  its  removal.  Bullets,  especially  if  smooth, 
often  become  encysted  and  may  remain  many  years  without  causing 
trouble.  Still,  the  extraction  of  the  ball,  fragments  of  wadding  or  cloth- 
ing, and  splinters  of  bone  hastens  the  cure  by  lessening  the  danger  of 
septic  inflammation  and  suppuration,  and  at  the  same  time  gets  rid  of  the 
po.ssibility  of  remote  inconvenience  from  encysted  bodies.  Hence,  the 
bullet  should  be  extracted,  if  it  can  be  done  either  through  the  opening 
of  entrance,  which  seldom  is  possible,  or  by  a  counter-incision.  Of  course 
if  the  wound  of  exit  proves  the  escape  of  the  entire  bullet,  and  no  foreign 
material  lies  in  the  wound,  these  measures  are  unnecessary.  The  wound 
should  be  made  aseptic  by  cleansing,  by  irrigation  with  sublimate  or 
betanaphthol  solution,  by  counter-openings  and  drainage,  and  should  be 
dressed  with  antiseptic  gauze. 

Gunshot  wounds,  in  which  nothing  except  the  bullet  has  entered  the 
tissues,  are  often  aseptic,  probably  because  the  missile  has  been  sterilized 
by  the  heat  generated  in  its  flight.  ]Much  harm  is  often  done  by  infecting 
such  a.septic  wounds  by  means  of  probes  and  fingers.  Unless  the  examina- 
tion is  aseptically  performed,  it  had  better  be  omitted,  and  the  wound 
dressed  with  antiseptic  gauze  until  a  proper  examination  in  skilled  hands 
is  obtained. 

To  determine  the  course  and  position  of  the  ball  careful  probing  with 
an  aseptic  finger  or  metal  probe  is  proper.  When  the  opening  involves 
the  abdominal,  cranial,  or  thoracic  cavity,  it  is  usually  justifial)le  to  make 
a  free  incision  under  rigid  asepsis  and  explore  the  contained  organs. 
This  important  topic  will  be  discussed  under  injuries  of  the  brain  and 
viscera.  In  abdominal  wounds  immediate  exploratory  operation  is  usu- 
ally demanded.  In  cranial  and  thoracic  wounds  delay  in  or  abstinence 
from  operation  may  be  proper. 

It  is  always  well  to  examine  the  surface  of  the  body  on  the  opposite 
side,  for  the  projectile  may  have  passed  across  and  be  lodged  under  the 
skin,  whence  an  incision  will  liberate  it.  For  probing  or  examining  the 
wound  the  patient  should  be  placed  in  the  position  occupied  when  shot, 
to  get  the  muscles  and  bones  in  the  same  mutual  relation.  The  probe 
should  be  slightly  bent  at  the  tip  to  enable  it  to  follow  tortuous  passages 
more  readily  as  it  is  delicately  inserted  and  turned  about  in  the  hand  of 
the  surgeon.     The  probe  of  Xelaton,  which  has  a  roughened  porcelain 


TREATMENT    OF    WOUNDS.  125 

tip,  may  be  serviceable,  because  it  becomes  marked  by  contact  with  the 
leaden  ball  and  thus  shows  that  the  hard  mass  touched  is  not  bone.  The 
electrical  apparatuses  for  determining  the  location  of  bullets  are  prac- 
tically valueless.  When  the  ball  has  been  found,  attempts  at  extraction 
are  to  be  made  with  the  various  forms  of  bullet-forceps  and  extractors. 
The  incision  may  be  freely  enlarged  if  necessary.  Unburnt  powder  about 
the  face  and  hands  is  to  be  removed  by  patient  picking  with  a  small 
knife,  or  by  cutting  out  little  disks  of  skin  with  an  instrument  like  a 
punch. 

Another  method  is  to  prick  the  skin  with  a  needle  dipped  in  croton  oil 
or  other  irritant,  which  causes  suppuration  and  leaves  only  minute  white 
scai's  instead  of  the  blue  powder  marks. 

When  extraction  has  been  accomplished  or  the  attempt  found  fruitless, 
the  wound  is  to  be  managed  on  the  general  antiseptic  principles  previously 
discussed.  Thorough  drainage  by  tubes  or  counter-incisions  is  resorted 
to  according  to  indications.  Immobilization  with  gypsum  bandages  over 
the  antiseptic  dressings  will  aid  in  protecting  the  injured  bones  from  undue 
motion, if  gunshot  fractui'e  exists.  Amputation  maybe  required  for  gun- 
shot injury  if  the  bones  are  greatly  shattered,  large  vessels  or  nerve-trunks 
destroyed,  joints  freely  exposed  with  comminution  of  bones,  or  if  rapidly 
spreading  mortification  is  threatened.  Primary  amputations  are  usually 
preferable  in  such  cases  to  secondary  operations. 

Excision  may  at  times  be  available  in  joint  injuries  or  in  gunshot 
fractures  of  the  shafts  of  long  bones. 


CHAPTER    X. 


PRACTICAL  SURGERY  AND  ANAESTHESIA. 

IxsTKUMEXT-?. — The  instruments  of  the  surgeon  are  innumerable,  but 
those  ordinarily  re(iuired  are  few  in  number  and  simple  in  construction. 
Knives,  force p.s,  scissors,  hemostatic  fon^eps,  saws,  needles,  probes,  and 
grooved  directors  are  indispensable  for  the  performance  of  surgical  opera- 
tions, and  undergo  many  modihcations  for  special  purposes.  Certain 
operations  demand  additional  instruments  of  peculiar  character,  such  as 
the  trocar,  catheter,  and  syringe.  A  knife  with  a  markedly  convex  or 
bellied  edge  is  technically  called  a  scalpel,  wliile  one  that  has  very  little 
belly  and  is  nearly  straight  is  termed  a  bistoury. 

Fig.  :'.s. 


Scalpel  with  aseptic  hollow  metal  liaiidle. 

Scalpels  are  usually  too  convex,  and  are  satisfactory  only  when  a  large 
flap  itf  skin  is  to  be  dissected  up.  A  knife  nearly  straight,  partaking, 
therefore,  of  the  character  of  the  bistoury,  is  the  best  form  and  answers 
equally  well  for  incisions,  dissections,  and  opening  abscesses  by  trans- 
fixion. 

Fk;.  .-,'.». 


Bistoury  with  aseptic  hollow  metal  handle. 


The  edge  of  a  knife  is  tested  by  drawing  it  from  heel  to  paint  across 
the  free  border  of  a  finger  nail,  for  by  this  manoeuvre  any  notches  will 
be  apparent.  Its  keenness  is  proved  by  the  ease  with  which  it  will  cut 
when  the  edge  is  gently  pressed  upon  the  skin  of  the  finger.  The  sharp- 
ness of  the  point  is  tested  by  the  thrusting  it  through  a  piece  of  kid  or 
gold-beaters'  skin  stretched  tightly  over  a  ring.  This  little  drum  gives 
out  a  distinct  sound  at  the  time  of  puncture  if  the  point  of  the  knife  is 
dull. 

Hemostatic  forceps  have  a  lock  and  are  used  to  compress-  wounded 
vessels  during  the  various  steps  of  an  operation,  so  that  the  surgeon  need 
not  be  delayed  by  ligating  bleeding  points.  In  truth  this  temporary 
compression  is  often  all  that  is  needed ;  for  small  vessels  soon  become  per- 
manently sealed  and  when  the  forceps  are  removed  require  no  ligature. 
Large  vessels  should  be  tied  before  the  hemostats  are  removed. 

Straight  needles  with  the  point  ground  on  three  sides,  such  as  are  used 
b}'  glovers,  are  nearly  always  preferable  to  those  curved  near  the  point. 


INSTRUMENTS. 


127 


They  penetrate  the  tough  skin  more  readily  and  enable  the  surgeon  to 
direct  the  point  more  certainly. 


Fig.  40. 

g.tiemamn  &  l"0 


Glover's  or  bayonet-point  needles,  enlarged. 


A  needle  fixed  in  a  handle  and  having  an  eye  in  the  point  is  often 
useful. 

The  sharp  hook  employed  for  drawing  out  the  ends  of  divided  vessels 
is  called  a  tenaculum.  It  has  been  supplanted  to  a  great  extent  by  the 
hemostatic  forceps.  Probes  should  always  be  firm,  but  sufficiently  flexible 
to  allow  the  operator  to  bend  the  end  slightly  before  beginning  to  explore 
a  sinus.  The  slightly  curved  extremity  will  follow  more  readily  the 
tortuosities  of  the  channel,  when  the  probe  is  rotated  in  the  fingers. 

Fig.  41. 


Sterilizing  oven  with  thermo-regulator  connected  with  gas  tube  to  prevent  temioerature 

rising  too  high. 

All  instruments  should  be  kept  scrupulously  clean  and  protected  from 
dust,  so  as  to  be  free  from  bacteria.  Dried  pus  and  blood  are  liable  to 
remain  in  crevices  of  instruments  and  infect  wounds  with  which  they 
come  in  contact.  The  eyes  of  catheters  and  the  teeth  of  forceps  are 
very  frequently  allowed  to  contain  foul  material  of  this  character.  Or- 
dinary dust  usually  contains  germs,  and  if  in  these  fissures,  may  infect 


128  PRACTICAL    SURGERY    AND    ANAESTHESIA. 

a  wound.  ^loist  or  dry  heat  is  the  only  perfect  sterilizer  of  instruments. 
They  should  always  be  washed  perfectly  clean  after  operation.  Just 
before  use  they  should  be  heated  to  at  least  212°  F.  and  kept  at  that 
temperature  for  ten  or  fifteen  minutes.  This  may  be  done  by  boiling  in 
water,  by  steam,  or  by  baking  in  an  oven.  The  handles  should  be  smooth 
and  of  metal  and  not  cemented,  since  cemented  instruments  are  damaged 
bv  heat.  All  unnecessary  complications  and  crevices  should  be  avoided. 
Copper  boxes  with  dust-tight  lids  are  convenient  receptacles  in  which  to 
keep,  bake,  and  transport  instruments. 

Fig.  42. 


Copper  boxes  for  sterilizing  instruments  by  baking. 

Incisions. — The  knife  should  always  be  held  delicately  though  firmly. 
The  most  common  position  of  the  knife  for  making  incisions  is  that 
assumed  when  one  uses  a  pen,  though  in  dissecting  up  large  flaps  the 
surgeon  will  often  hold  the  knife  as  if  it  were  a  fiddle-bow.  Occasion- 
ally, as  in  amputations,  the  large  handle  is  firmly  grasped  with  the  entire 
hand.  When  an  incision  is  to  l)e  made  the  fingers  of  the  left  hand  should 
support  the  skin  at  the  point  where  the  knife  is  to  be  entered,  the  surgeon 
then  thrusts  the  point  into  the  tissues  perpendicularly  and,  immediately 
depressing  the  handle  of  the  knife,  cuts  with  the  edge  until  the  incision 
is  sufliciently  long ;  he  should  then,  in  order  that  the  tissues  may  all  be 
completelv  divided  to  the  very  end  of  the  incision,  elevate  the  handle 
and  bring  the  knife  out  perpendicularly. 

Incisions  should  be  sufficiently  large  to  expose  the  parts  and  should  be 
made  with  decided  strokes  of  the  knife.  Nothing  discloses  the  inefficient 
surgeon  so  much  as  small  button-hole  like  incisions,  made  by  picking 
with  the  point  of  the  knife.  When  possible,  incisions  about  the  face 
should  follow  the  cutaneous  creases  that  the  scars  may  be  as  unnoticeable 
as  possible.  Oblicpie  division  of  the  skin  causes  slight  scarring,  and  curvi- 
linear incisions  are  less  noticeable  than  straight  ones.  In  making  incisions 
over  large  vessels  or  important  organs  the  grooved  director  is  to  be  pushed 
under  the  successive  layei-s  of  tissue  before  the  knife  is  used  to  divide 
them.     This  does  not  apply  to  the  skin  incision. 

An.'esthesia. 

For  trivial  operations,  such  as  opening  abscesses  and  removing  small 
tumors,  local  anresthesia  is  sufficient.  It  is  induced  in  one  or  two  minutes 
by  applying  a  lump  of  ice  or  a  mixture  of  ice  and  salt  to  the  skin  ;  by 
blowing  ether,  rhigolene,  or  other  refrigerating  vapor  upon  the  surface 
with  an  atomizer,  or  by  employing  cocaine  hydrochlorate. 


ANESTHESIA.  129 

Local  anEesthesia  obtained  by  the  use  of  aqueous  solution  of  hydrochlo- 
rate  of  cocaine  is  eminently  satisfactory.  A  twenty  grain  solution  of  this 
salt  in  water  painted  upon  a  mucous  membrane  with  a  camel's-hair  pencil, 
or  dropped  upon  it  from  a  medicine  dropper,  will  produce  local  anaesthesia 
in  about  three  minutes  and  will  permit  the  performance  of  any  minor  opera- 
tion without  giving  the  patient  pain.  If  the  application  first  made  does  not 
produce  insensibility  to  pain  in  the  part  to  which  it  is  applied,  a  repeated 
application  may  be  made  in  a  similar  manner.  The  anaesthesia  thus 
produced  lasts  a  number  of  minutes.  It  is  important  that  the  part  to 
which  the  anaesthetic  is  applied  should  not  be  alkaline  in  reaction,  since 
alkalinity  of  the  surface  interferes  with  the  anaesthetic  power  of 
cocaine. 

Local  anaesthesia  cannot  be  produced  in  the  skin,  as  in  mucous  mem- 
branes, by  merely  painting  or  brushing  the  surface  with  the  solution, 
except  for  operations  made  upon  very  thin  skin,  as  that  of  the  eyelids. 
For  cutaneous  operations  of  a  superficial  character  it  is  sufiicieut  to  inject 
the  cocaine  into  or  under  the  skin  by  a  hypodermic  syringe.  From  five 
to  twenty  minims  should  be  introduced  by  one  or  two  punctures.  If  moi'e 
perfect  local  anaesthesia  is  desired,  as  for  the  removal  of  small  tumors,  the 
solution  can  often  be  incarcerated  in  the  part,  into  which  it  has  been 
injected,  by  retarding  the  venous  return  from  the  cocainized  area  by  means 
of  a  ligature  or  a  rubber  ring.  If  an  operation  is  to  be  made  upon  a 
finger  or  upon  the  penis,  for  example,  the  anaesthetic  will  last  longer  and 
prove  more  effective  if  it  is  incarcerated  at  the  seat  of  operation  by  tying 
a  piece  of  tape  or  placing  a  rubber  band  around  the  base  of  the  member 
before  the  hypodermic  injection.  If  an  operation  is  to  be  made  upon  the 
eyelids  or  upon  very  thin  skin,  but  not  at  a  very  great  depth,  a  sufficient 
degree  of  painlessness  can  be  obtained  by  simply  painting  the  thin  skin 
with  the  solution  in  very  much  the  same  manner  as  is  done  in  operations 
on  mucous  membrane.  In  all  such  instances  the  surface  should  not  be 
alkaline,  else  the  anaesthetic  power  of  the  drug  will  not  be  exerted. 

It  must  be  remembered  that  death  has  occurred  from  cocoaine  poisoning. 
It  is  best,  therefore,  to  avoid  the  toxic  affect  by  not  using  a  solution 
stronger  than  twenty  grains  to  the  ounce,  and  it  is  wise  seldom  to  use  more 
than  twenty  minims  at  the  most,  unless  the  drug  has  been  incarcerated. 
Then  after  operating  the  surgeon  can  by  intermittent  relaxation  allow  it 
to  enter  the  system  gradually.  The  passage  of  urethral  bougies  and  instru- 
ments of  a  similar  character  may  be  rendered  quite  painless  by  injecting 
the  urethra  with  cocaine.  When  used  upon  the  eye  in  large  quantity 
and  in  too  strong  solution  it  occasions  opacity,  temporary  however,  of  the 
cornea,  and  may,  therefore,  possibly  do  harm  if  it  is  not  used  with 
proper  caution. 

For  the  production  of  general  anaesthesia  in  surgery  ether  is  preferable 
to  any  other  agent  at  present  generally  employed.  Chloroform  is  much 
more  dangerous.  This  is  a  sufficient  cause  for  the  abolition  of  its  use. 
Its  claimed  advantages  over  ether  are  considerably  overrated  because  of 
the  improper  methods  in  which  ether  is  often  given. 

Nitrous  oxide  is  not  a  good  anaesthetic  for  protracted  operations,  requires 
bulky  apparatus  for  its  administration,  and  in  short  operations  can  readily 
be  substituted  by  local  anaesthesia  or  the  primary  anaesthesia  of  ether. 

Rapidly  repeated  deep  inspirations  continued  for  a  minute  or  so  will 
produce  insensibility  to  pain  (analgesia)  for  slight  operations,  though  the 
sensibility  to  contact  is  not  obliterated.     This  effect  may  be  utilized  in 

9 


130  I'RACTICAL    SURGERY    AND    ANESTHESIA, 

surgery,  but  it  and  anaesthesia  from  nitrous  oxide  are  us^ed  very  little 
outside  of  dentistry. 

Before  etherizing  a  patient  the  surgeon  should  examine  the  kidneys, 
heart,  and  lungs.  The  presence  of  disea.<e  in  one  or  all  of  these  organs 
should  not  deter  one  from  the  administration  of  ether  when  necessary  for 
a  painful  operation  ;  but  the  knowledge  of  its  existence  renders  one 
exceedingly  cautious,  and  protects  him  against  the  verdict  of  carelessness 
in  the  event  of  dangerous  symptoms  or  a  fatal  result. 

Anaesthesia  is  always  a  dangerous  condition,  and  requires  the  undivided 
attention  of  an  experienced  assistant.  Death  has  occurred  not  infre- 
quently from  etherization  and  often  from  chloroform  anaesthesia. 

The  patient's  stomach  should  be  empty,  lost  vomiting  occur  during  or 
after  anaesthesia.  Hence,  he  should  fast  for  four  or  six  hours  prior  to 
etherization,  and  it  is  even  better  ii' no  solid  food  has  been  taken  since  the 
previous  day.  A  hypodermic  injection  of  morphia  (gr.  ^  to  gr.  \)  and 
atropia  (gr.  y^^  to  gr.  ■^\)  should  be  administered  about  hfteen  minutes 
before  inhalation  is  begun.  This  renders  aniesthesia  quieter,  more  rapid, 
and  more  safe.  It  is  not  an  absolute  essential  but  is  very  judicious.  All 
clothing  restricting  deep  inspiration  must  be  removed  or  loosened.  It  is 
important  to  insist  upon  women  unfostening  their  corsets  and  the  skirts 
tied  about  the  waist.  Do  not  trust  to  the  assertion  that  their  clothes  are 
not  tight.  False  teeth  and  pieces  of  tobacco  must  be  removed  from  the 
mouth,  because  of  the  danger  of  their  falling  backward  into  the  fauces 
and  obstructing  respiration.  The  patient  is  usually  placed  in  the  recum- 
bent position,  unless  the  operation  is  about  the  mouth  or  nose,  when  the 
semi-recumbent  posture  is  better,  as  it  prevents  the  blood  flowing  back 
into  the  pharynx.  The  semi-recurabent  or  sitting  posture  is  not  justifiable 
during  chloroform  inhalation.  In  operations  upon  the  nose  and  palate  it 
is  often  better  to  have  the  patient  lying  on  his  back  with  the  head  so  bent 
backward  that  the  palate  is  lower  than  the  floor  of  the  mouth.  Blood  is 
thus  kept  away  from  the  site  of  ojjeration  and  yet  does  not  flow  into  the 
larynx,  causing  choking  and  coughing.  When  these  preliminaries  have 
been  arranged  the  patient  is  shown  how  to  inspire  and  expire  deeply,  and 
is  encouraged  to  do  so  for  a  few  moments.  I  sometimes  tranquillize  ray 
patients  and  teach  them  to  breathe  properly  by  placing  the  dry  towel 
over  the  face  for  a  few  seconds  before  adding  ether. 

No  inhaling  apparatus  is  required.  A  cone  of  paper  containing  a 
loosely  folded  towel  is  a  very  satisfactory  contrivance ;  but  a  small  napkin 
or  a  handkerchief  loosely  folded  and  covered  by  a  large  towel  .so  that  the 
ether  vapor  cannot  escape  is  usually  preferable.  The  outer  towel  should 
cover  the  eyes  of  the  patient,  and  no  talking  on  the  part  of  the  bystanders 
should  be  allowed  until  insensibility  occurs.  The  senses  of  sight  and 
hearing  should  not  be  stimulated  by  any  such  disturbing  influences.  The 
ether  vapor  must  be  given  in  a  concentrated  form,  and  from  one  to  two 
fluidounces  should  be  poured  on  the  napkin  at  first,  that  renewal  may 
not  often  be  required.  When  inhalation  has  once  fairly  begun  the  ether 
cloth  should  never  be  removed  from  the  face,  unless  spasm  of  respiration 
or  actual  vomiting  necessitates  its  temporary  withdrawal.  It  should  be 
held  closely  to  the  nose  and  mouth ;  sufficient  air  will  reach  the  lungs 
through  the  meshes  and  folds  of  the  towel.  The  patient  becomes  ex- 
cited, the  surgeon  irritated,  and  the  stage  of  etherization  greatly  pro- 
longed by  the  etherizer  allowing  a  large  amount  of  air  to  mix  with  the 
anaesthetic  vapor.  Frequently,  indeed,  I  have  seen  the  cloth  taken 
entirely  away  from  the  face  while  additional  ether  was  being  poured  on 


ANESTHESIA.  .  131 

the  napkin.  This  is  mismanagement,  for  it  allows  the  stage  of  excite- 
ment to  be  prolonged,  and  condemns  the  patient  to  a  protracted  anaes- 
thesia which  increases  the  danger  of  subsequent  bronchial  irritation  and 
cardiac  depression.  If  the  room  is  kept  quiet,  the  patient  previously 
taught  how  to  breathe  deeply,  a  full  amount  of  ether  poured  on  the  towel, 
the  eyes  of  the  patient  covered,  and  no  air  admitted  to  the  lungs  except 
that  which  passes  through  the  towel,  complete  angesthesia  can  be  obtained 
in  from  three  to  ten  minutes  in  nearly  every  instance.  It  is  not  safe  to 
give  chloroform  in  this  manner. 

During  the  entire  period  of  etherization  the  administrator  must  care- 
fully watch  the  respiration,  color  of  skin,  and  pulse.  The  first  two  points 
demand  especial  scrutiny,  but  the  changes  in  cardiac  force,  which  can  be 
most  conveniently  investigated  at  the  temporal  artery  in  front  of  the  ear, 
must  not  escape  examination. 

It  occasionally  happens  that  after  a  few  inhalations  have  been  taken  a 
spasm  of  respiration  takes  place,  evinced  by  absence  (^f  inspiratory  effort 
and  cyanosis  of  the  face.  This  calls  for  the  withdrawal  of  the  ether  for 
a  moment,  when  a  deep  inspiration  occurs,  and  no  further  symptoms  of 
asphyxia  are  shown.  If  in  the  stage  of  excitation  the  patient  struggles 
and  cries  out,  the  ether  cloth  must  be  kept  closely  applied,  because  access 
of  air  increases  the  excitement.  The  crying  and  shouting  are  desirable 
at  times,  because  by  the  deep  inspirations  necessitated  inhalation  is  more 
quickly  accomplished.  Retching  as  if  vomiting  was  about  to  occur  is  an 
indication  to  keep  up  the  ether.  During  complete  ansesthesia  vomiting 
does  not  take  place.  If,  however,  the  stomach  contents  are  regurgitated 
upward  into  the  pharynx  and  mouth,  the  ether  must  be  stopped  until  the 
fauces  are  cleared  of  materials  that  might  pass  into  the  larynx.  The 
suspension  of  inhalation  should  be  as  momentary  as  possible.  Sometimes 
the  ether  vapor  causes  an  abundant  secretion  of  bronchial  mucus,  which 
collects  in  the  larynx  and  fauces  and  causes  impeded  respiration.  This 
complication  is  met  by  clearing  the  throat  with  a  finger  introduced  into 
the  mouth,  or  by  turning  the  patient  on  his  face  for  a  moment  with  his 
head  hanging  down  over  the  edge  of  the  operating-table. 

When  the  conjunctiva  is  insensible  to  touch  with  the  finger,  the  muscular 
relaxation  complete,  and  a  tendency  to  stertorous  breathing  noticeable,  the 
time  for  operating  has  arrived.  The  ether  may  then  be  withdrawn  or 
only  administered  in  sufficient  quantities  to  keep  up  the  anaesthetic  state 
without  inducing  a  continuance  of  loud  palatal  and  laryngeal  stertor. 
Stertorous  respiration  usually  means  that  ansesthesia  should  not  be  pushed, 
since  the  patient  is  then  insensible  to  pain. 

There  is  a  primary  anaesthesia  lasting  about  a  minute  which  is  asso- 
ciated with  muscular  relaxation  and  occurs  soon  after  inhalation  has 
begun.  This  stage  of  etherization  may  be  utilized  for  the  performance 
of  such  operations  as  opening  abscesses  and  extracting  teeth.  The  re- 
covery from  this  anaesthetic  condition  is  very  prompt  and  unattended  with 
the  nausea  and  other  after-effects  of  prolonged  etherization.  This  primary 
anaesthesia  or  first  insensibility  of  ether  is  not  sufficient  for  other  than 
minor  surgical  operations.  It  resembles  to  my  mind  the  analgesic  effects 
of  rapid  respiration,  previously  mentioned,  more  than  true  anaesthesia. 

In  all  administrations  of  ether  it  must  be  remembered  that  its  vapor  is 
inflammable  and  so  dense  that  it  falls  toward  the  floor ;  therefore  all 
candles  or  other  lights  should  be  placed  at  a  distance  from  the  patient 
and  at  a  higher  level  than  the  operating  table. 

When  patients  regain  consciousness  after  etherization  they  occasionally 


132  PRACTICAL    SURGERY    AND    ANESTHESIA. 

become  very  noisy  and  hysterical.  The  shoutinif  can  be  stopi)ed  by  pour- 
ing a  little  water  into  the  mouth  every  time  the  patient  opens  it  to  cry 
out.  This  compels  him  to  close  his  mouth  to  swallow.  If  the  nostrils 
are  closed  by  one  hand  of  the  attendant  while  the  other  hand  administers 
frequent  doses  of  water,  the  patient  soon  becomes  too  much  occuj)i(d  with 
swallowing  and  mouth  breathing  to  think  of  making  further  outcry.  If 
dangerous  symptoms,  such  as  asphyxia,  or  cardiac  failure,  occur  during 
the  administration  of  an  amesthetic  the  inhalation  must  at  once  be  sus- 
pended. If  mucus  or  vomited  matters  produce  interference  with  respira- 
tion they  must  be  promptly  removed.  Tracheotomy  might  be  demanded 
when  ankylosis  of  the  jaws  or  other  causes  interfered  with  proper  clear- 
ance of  the  larynx.  Imperfect  respiration  may  be  due  to  an  eHect  of  the 
ether  on  the  nerve-centres.  Pulling  the  tip  of  tiie  tongue  forward  and 
far  out  of  the  mouth  often  aids  the  respiratory  function,  but  artificial 
respiration  and  electrical  stimulus  may  occasionally  be  required.  In  many 
cases  dashing  cold  water  in  the  face,  slapping  the  cheeks  with  a  towel 
dipped  in  water,  or  pouring  a  little  ether  upon  the  epigastrium  is  sufficient. 
Pushing  the  lower  jaw  upward  and  forward  has  been  recommended  as  a 
valuable  procedure. 

Heart  failure  producing  anaemia  of  the  brain  is  combated  by  inversion 
of  the  body,  perfect  muscular  (juiescence,  and  inhalations  of  nitrite  of 
amyl.  In  addition  atropia,  digitalis,  and  j)erhaps  ammonia  should  be 
given  hypodermically  in  full  doses  to  combat  the  toxic  effects  of  ether. 
Experimental  investigation  in  physiological  laboratories  seems  to  prove 
that  alcohol  is  injudicious  in  the  treatment  of  ether  poisoning.  It  should, 
therefore,  not  be  given  in  such  cases.  If  this  experimental  evidence  is 
accepted  it  is  improper  to  administer  alcohol  before  etherization  to  avert 
shock.     (Quinine,  atropia,  digitalis,  and  morphia  are  preferable. 

Persons  addicted  to  alcoholic  stimulation  re(|uire  more  ether  to  induce 
profound  antesthesia  than  temperate  ones,  because  they  have  become 
habituated  to  the  effects  of  similar  intoxicating  agents.  The  administra- 
tion of  the  anpesthetic  must  be  cautious,  because  the  viscera  of  drunkards 
are  frequently  diseased. 

It  is  unwise  to  etherize  a  ])atient  without  assistance,  because  dangerous 
symptoms  might  arise  from  the  anaesthetic  or  the  operation,  and  the  sur- 
geon would  be  unable  to  give  efficient  aid  alone.  A  woman  should  never 
be  etherized  by  a  man  unless  a  third  person  is  present,  since  a  charge  of 
criminal  as.sault  might  be  made  because  of  erotic  dreams  during  the 
amesthetic  state. 


CHAPTER    XI. 

OPERATIVE    SUEGEEY. 

PREPARATION    OF   THE   PATIENT   AND    THE   SURGEON   AND    MODE  OF 
CONDUCTING   OPERATIONS. 

The  preparatory  treatment  of  persons  about  to  undergo  operations  that 
do  not  require  immediate  execution  is  important.  Debilitated  patients 
should  be  built  up  by  food  and  tonic  regimen  ;  those  of  an  opposite  con- 
stitution may  require  more  moderate  diet  than  usual,  purgation,  and 
some  restriction  as  to  stimulants. 

Peculiarities  of  disposition  and  constitution  should  be  studied  by  the 
surgeon,  since  the  existence  of  the  hemorrhagic  diathesis,  a  tendency  to 
delirium  or  any  other  marked  habit  of  body  might  influence  the  choice 
of  methods  of  operating.  Encouraging  words  are  of  great  value  in  sus- 
taining the  spirits  of  timid  patients.  All  patients,  if  placed  in  a  hospital 
or  removed  from  their  homes,  should  ordinarily  be  allowed  a  day's  delay 
in  order  to  become  accustomed  to  strange  surroundings,  nurses,  beds,  etc. 
If  restraint  of  a  limb  in  one  position  is  essential  to  the  success  of  an 
operation,  it  is  well  to  keep  the  limb  in  that  abnormal  posture  for  a  day 
or  two  that  the  weariness  so  caused  may  pass  away.  Menstruation  if 
normal  does  not  seem  much  of  a  contra-indication  to  operation,  though 
the  time  between  the  periods  should  ordinarily  be  selected.  Pregnancy 
is  usually  a  proper  cause  of  delay  in  operations  of  expediency.  The 
seat  of  operation  must  always  be  rendered  aseptic  by  shaving,  so  as  to 
remove  the  fine  hairs  which  may  retain  dust  and  germs,  and  by  subsequent 
thorough  scrubbing  of  the  skin  with  soap  and  water.  A  second  washing 
with  a  sublimate  solution  (1  :  1000)  is  then  proper.  Before  serious  ope- 
rations the  patient  should,  if  possible,  be  given  in  addition  a  full  bath 
the  evening  previous.  This  is  to  avoid  septic  contamination  from  bac- 
teria on  the  skin.  The  umbilicus  and  the  folds  of  the  skin  about  the 
groins,  axillse,  and  toes  are  especially  apt  to  be  overlooked  in  these 
cleansing  processes.  The  secretions,  epidermis,  and  dirt  retained  there 
are  full  of  bacteria,  as  are  the  spaces  underneath  the  nails  of  the  patient 
as  well  as  of  the  surgeon. 

A  good  light  and  a  bright,  cheerful  day  are  important  factors  in  se- 
curing the  best  conditions  for  operative  surgery.  A  patient  should  never 
be  kept  waiting  by  the  surgeon  after  the  appointed  hour.  Anxiety  and 
suspense  induce  nervousness.  I  always  endeavor  to  arrive  before  the 
time  agreed  upon  so  as  to  anticipate  the  worrying  period. 

It  becomes  necessary  at  this  point  to  enter  with  more  detail  into  the 
matter  of  asepsis  and  antisepsis. 

By  asepsis  is  meant  absence  of  all  vegetable  parasites  or  microorganisms. 
The  word,  therefore,  is  employed  to  signify  that  the  surgeon  has  used 
every  effort  to  prevent  the  presence  of  any  such  organisms  in  the  wound ; 
and  implies,  therefore,  the  absence  of  such  parasites  from  the  surgeon's 


134  OPERATIVE    SURGERY. 

haiuls,  from  the  instruments  use<l,  i'rom  tlie  dressings  applied  and  from 
the  surroundings.  Ase})sis  then,  or  aseptic  surgery,  means  that  the  pro- 
cedure is  germ  free. 

By  antisepsis  is  meant  tliat  the  manipulations  are  directed  toward  the 
destruction  of  all  microorganisms  which  may  be  present.  In  the  one 
case  the  endeavor  is  to  obtain  perfect  freedom  from  pathogenic  organisms  ; 
in  the  other  case  it  is  to  destroy  any  pathogenic  organisms  which  may  be 
present  in  the  wound,  upon  the  hands  of  the  surgeon,  or  upon  the  dress- 
ings. If  absolute  asepsis  could  always  be  assured,  anti.sepsis  would  be 
unnecessary.  It  is  because  there  are  so  many  sources  by  which  bacteria 
may  get  into  a  wound,  even  when  done  under  the  supervision  of  the  most 
careful  surgeon,  that  many  of  us  prefer  to  use  antiseptic  precautions  in 
addition  to  cleansing  the  skin  of  the  patient,  scrubbing  the  surgeon's 
hands,  and  sterilizing  the  instruments  and  sponges. 

In  some  eases  the  use  of  chemical  agents  may  be  deleterious  because 
they  act  upcm  the  patient's  tissues  in  such  a  way  as  to  produce  irritation  ; 
at  least,  such  is  the  case  when  they  are  ap])lied  in  sufficient  strength  to 
render  their  antiseptic,  propei'ties  valuable.  For  example,  an  ordinary 
solution  of  carbolic  acid  or  corrosive  sublimate  can  never  be  put  into  the 
peritoneal  cavity  without  danger.  It  is  also  possible  that  frequent  wash- 
ing of  recent  wounds  with  such  solutions  irritates  the  tissues  and  leads  to 
greater  exudation  of  serum  after  the  lips  of  the  w-ound  have  been  ap- 
proximated than  would  be  the  case  if  the  wound  was  not  subjected  to 
such  irritation. 

As  has  been  said  in  an  earlier  chapter,  heat  is  the  most  perfect  destroyer 
of  vegetable  fungi ;  therefore,  instruments,  sponges  and  dressings,  which 
have  been  sufficiently  heated  are  free  from  germs.  If  the  instruments 
and  sponges  are  kept  in  the  water  in  which  they  have  been  boiled  they 
can  be  used  with  impunity,  provided  that  dust  is  prevented  from  falling 
into  the  receptacle.  Such  sterilized,  or  aseptic,  water  is  far  less  irritating 
than  water  containing  chemical  antiseptics. 

The  antiseptic  solution  most  often  used  for  washing  the  skin  of  the 
patient  and  for  scrubbing  the  surgeon's  hands  is  water  containing  corrosive 
sublimate  in  the  proportion  of  1  :  1000  or  1  :  2000.  This  solution,  how- 
ever, is  too  strong  to  be  used  for  irrigating  cavities,  because  if  any  portion 
of  the  fluid  should  remain,  as  it  often  will  do,  there  is  great  danger  of 
producing  corrosive  sublimate  poisoning.  This  is  evidenced  by  the 
occurrence  of  vomiting  and  bloody  stools.  Betanaphthol  (1  :  2500)  is 
preferable  for  washing  out  such  cavities  because  it  is  a  non-poisonous 
agent.  Betanaphthol,  however,  is  not  as  powerful  a  parasiticide  as  cor- 
rosive sublimate.  Boiled  water,  or  steam  which  has  been  condensed  in 
clean  receptacles,  should  be  used  for  alxlominal  operations. 

Sublimate  solution  should  never  be  used  to  sterilize  instruments,  because 
it  tarnishes  the  steel  and  dulls  the  edges  of  cutting  instruments.  For 
such  purposes  a  betanaphthol  solution  or  a  solution  of  carbolic  acid 
(1 :  40)  should  be  employed.  If  the  surgeon  prefers  he  may  boil  his  in- 
struments and  let  them  stand  in  the  water  until  it  has  sufficiently  cooled 
to  allow  him  to  put  his  hands  in  it  or  until  he  is  ready  for  their  use.  The 
vessels  should  be  protected  from  atmospheric  dust  by  covers.  I,  myself, 
prefer  betanaphthol  solution,  as  a  rule,  for  instruments,  because  it  does 
not  irritate  the  skin  of  the  surgeon's  hands  as  do  corrosive  sublimate  and 
carbolic  acid,  and  because  it  is  safer  than  boiled  water  as  it  is  antiseptic 
instead  of  merely  aseptic.  The  sterilization  of  instruments  by  baking  in 
copper  boxes  has  already  been  described. 


PREPARATION    OF    THE    PATIENT.  135 

Wlien  an  operation  is  to  be  performed  the  instruments  required  should 
previously  be  put  in  trays  containing  sterilized  water  or  antiseptic  solu- 
tion, and  these  trays  should  be  set  upon  a  table  without  being  seen  by  the 
family  or  patient.  All  sponges,  sutures  and  dressings  must  be  sterile. 
The  patient's  skin  must  be  made  aseptic  by  thorough  cleansing,  the 
surgeon's  finger-nails  cleaned  and  his  hands  and  arms  scrubbed  with  soap 
and  made  free  from  possible  pathogenic  germs,  his  clothing  covered  with 
a  clean  operating  apron,  and  his  sleeves  rolled  up  to  the  elbow  ;  just  before 
operating  his  hands  should  be  dipped  in  a  sublimate  solution  (1  :  1000) 
for  a  couple  of  minutes  and  the  jDatient's  skin  washed  with  a  similar 
solution.  Every  assistant  should  know  his  duty  and  attend  to  it  alone. 
And  no  loud  talking  or  unseemly  jesting  should  be  permitted.  The 
assistants  whose  hands  are  to  touch  sponges,  instruments,  and  the  wound 
must  be  as  aseptic  as  the  surgeon.  oSTo  one  else  should  be  allowed  to 
handle  anything.  Xothing,  unless  it  is  germ  free,  is  permitted  to  come 
into  contact  with  the  incised  tissues.  An  instrument  which  has  dropped 
upon  the  floor  or  touched  the  bedclothes  must  be  rejected  until  again 
sterilized.  The  surgeon  must  touch  nothing  that  is  not  sterile,  unless  he 
sterilizes  his  hands  again  with  an  antiseptic  solution  or  washes  them  in 
sterilized  water  before  approaching  the  wound.  He  dare  not  put  his 
hands  into  his  pocket  or  scratch  his  head  or  face  without  endangering 
the  patient's  life  by  the  possible  conveyance  of  a  single  bacterium  into  the 
wound.  It  is,  therefore,  well  to  surround  the  seat  of  operation  with  steril- 
ized towels  laid  over  the  clothing  or  bed  coverings.  These  may  be  baked 
towels  or  towels  soaked  in  sublimate  solution  and  dried.  A  table  or  firm 
bed  is  preferable  to  a  reclining  chair  because  more  steady,  and  not  so 
easily  disarranged  by  struggles  during  etherization.  The  patient's  body 
and  limbs  should  be  covered  and  not  exposed  to  the  chilling  influence  of 
the  air. 

A  skilful  surgeon  usually  has  the  whole  plan  of  the  operation  clear  in 
his  mind  before  starting,  and  proceeds  to  its  completion  by  successive 
steps  with  confidence  and  without  hurry.  Where  uncertainty  of  diagnosis 
exists,  the  plan  of  procedure  may  require  modification  as  the  condition  is 
revealed  ;  but  this  is  very  different  from  the  vacillating  course  of  the  man 
who  undertakes  an  operation  without  knowing  exactly  what  he  expects  to 
do  and  constantly  appeals  to  the  surgical  spectators  for  suggestions. 

The  occurrence  of  hemorrhage  should  be  precluded  by  the  use  of  the 
Esmarch  elastic  bandage,  or  by  acupressure  or  digital  pressure  to  the 
main  arterial  trunk.  Much  of  the  depression  formerly  attributed  to 
shock  was  really  due  to  hemorrhage  occurring  after  injury  or  during 
operation.  The  surgeon  should  not,  however,  stop  in  operations  to  ligate 
the  numerous  little  branches  that  bleed ;  for  many  of  them  will  cease 
spontaneously,  and  others  can  be  controlled  by  hemostatic  forceps,  applied 
by  the  assistants,  until  the  operation  is  completed.  Then  ligatures  can 
be  used.  In  operations  about  the  face  it  is  especially  noticeable  that 
small  vessels  spurt  very  vigorously  for  a  moment  or  so,  but  soon  stop  with- 
out ligation. 

In  major  operations,  as  for  the  removal  of  tumors  for  example,  the 
most  difficult  points  should  be  attacked  first.  Let  the  operator  get  under 
the  mass,  if  it  be  a  tumor,  as  soon  as  he  has  made  his  cutaneous  incision. 
Then  he  knows  what  he  has  to  meet,  and  having  controlled  the  sources  of 
hemorrhage  and  mastered  the  grave  complications,  he  can  dextrously  and 
with  facility  complete  the  work  of  removal. 


186  OPERATIVE    SURGERY. 

The  principles  or  fundamental  laws  of  operative  surgery  are: 

1.  Obtain  the  services  of  an  etherizer  who  will  not  require  you  to  super- 
intend the  ana?sthetic. 

2.  Take  j)recautions  to  prevent  hemorrhage,  if  the  locality  renders  this 
possible. 

3.  After  proper  thought  and  consultation  have  the  plan  of  operation 
clearly  outlined  in  your  own  mind. 

4.  Have  the  patient,  the  instruments,  yourself  and  your  assistants  abso- 
lutely aseptic. 

5.  Proceed  svstematically  with  the  steps  of  the  operation  decided  upon, 
and  do  not  be  led  into  a  mixed  oi)eration  by  bystanders,  unless  unexpected 
developments  in  diagnosis  occur. 

6.  Attack  the  greatest  difficulties  and  dangers  of  the  operation  first. 

7.  Do  not  stop  to  tie  any  except  large  vessels,  but  let  assistants  apply 
hemostatic  forceps,  or  make  pressure  with  their  fingers  until  incisions  are 
completed. 

8.  AVhen  the  operation  is  finished,  stop  hemorrhage  and  apply  dressings. 

9.  Finally,  remember  that  suppuration  in  an  operation  wound  is 
usually,  probably  always,  due  to  careless  asepsis  on  the  part  of  the  sur- 
geon or  his  assistants,  except  in  those  instances  where  the  operation  is 
done  on  tissues  already  suppurating. 

Control  of  Hemorrhage. 

The  prevention  and  management  of  hemorrhage  during  operations  will 
be  considered  in  the  chapter  on  Diseases  and  Injuries  of  Bloodvessels. 

Sutures. 

When  a  wound  has  a  tendency  to  gape,  and  there  is  a  probability  that 
union  by  first  intention  can  be  secured  by  correct  apposition  of  the  edges, 
sutures  are  employed.  They  should  not  be  used  in  contused  and  lacer- 
ated wounds,  intension  is  induced  by  adjusting  the  parts,  or  if  the  wound 
is  not  perfectly  aseptic,  and  there  is  danger  of  preventing  thereby  the 
free  escape  of  serum  and  pus. 

The  suturing  materials  most  commonly  used  at  the  prasent  time  are 
catgut  and  silk.  Occasionally  wire  or  wormgut  sutures  are  employed.  It 
goes  without  saying  that  these  sutures  must  be  rendered  aseptic,  in  order 
that  they  may  not  induce  suppuration  or  other  pathological  conditions 
in  the  tissues  into  which  they  are  inserted.  Wire  and  silk  sutures  are 
rendered  aseptic  by  baking,  or  by  soaking  in  a  strong  antiseptic  solution. 
Catgut  is  prepared  and  then  kept  in  an  antiseptic  solution  until  it  is  used. 
I,  myself,  prefer  catgut  kept  in  alcohol,  because  the  oily  menstrua  in 
which  it  is  .sometimes  preserved  make  it  disagreeable  to  handle.  Anti- 
septic catgut  and  silk  sutures  and  wire  for  suturing  can  be  obtained  from 
the  instrument-makers.  Surgeons  often  prepare  the  catgut  sutures  and 
ligatures  themselves,  by  purchasing  violin  strings  and  rendering  them 
antiseptic  by  some  such  formula  as  the  following  :  Soak  the  catgut  violin 
strings  in  oil  of  juniper  wood  for  forty-eight  hours,  in  order  to  remove  the 
fat ;  then  wash  in  alcohol,  and  store  in  fresh  alcohol  until  required  for 
use.  It  is  best  to  thread  the  needles,  which  should  be  aseptic,  before  they 
and  the  gut  are  put  in  the  antiseptic  trays  used  at  the  operation ;  because 
the  catgut,  when  taken  from  the  alcohol,  is  somewhat  stifle  and  shrunken, 
but  when  put  in  water  becomes  swollen  and  cannot,  therefore,  be  threaded 


SUTURES.  137 

through  needles  with  ordinary  eyes.  Such  catgut  sutures  will  become 
absorbed  by  the  tissues  in  which  they  are  placed  in  from  five  to  ten  days, 
varying  according  to  the  thickness  of  the  thread.  If  it  is  desired  to  pre- 
vent the  absorption  of  the  sutures  at  such  an  early  period — as  happens,  for 
example,  when  tendons  or  bones  have  been  sutured — it  is  proper  to  use 
chromicized  gut.  This  is  catgut  rendered  less  absorbable  than  ordinary 
antiseptic  gut  by  the  addition  of  chromic  acid  to  the  solution  in  which  it 
is  prepared.     To  chromicize  catgut  the  following  formula  is  a  good  one  : 

After  having  soaked  the  gut  in  oil  of  juniper  wood  for  forty-eight  hours, 
wash  it  in  alcohol  and  let  it  soak  for  forty-eight  hours  in  a  solution  pre- 
pared according  to  the  following  formula :  Carbolic  acid,  1  part ; 
chromic  acid,  ^^  part ;  water,  20  parts ;  catgut,  1  part.  After  standing 
in  this  solution  forty-eight  hours  the  sutures  should  be  washed  in  alcohol, 
and  then  preserved  in  fresh  alcohol.  Sutures,  or  ligatures,  prepared  in 
this  way  will  be  absorbed  in  from  ten  to  thirty  days,  according  to  the 
thickness  of  the  thread.  The  thicker  the  thread  the  longer  the  time 
required  for  absorption. 

Since  they  are  not  absorbed  in  the  tissues  for  many  days,  chromicized 
catgut  sutures  can  often  be  used  with  advantage  where  wire  sutures  were 
formerly  and  are  often  still  used.  The  advantage  of  catgut  sutures, 
whether  chromicized  or  not,  is  that  the  surgeon  does  not  have  to  withdraw 
them  after  union  has  taken  place,  as  is  the  case  when  wire  sutures  are 
used.  Silk  sutures  are  often  cut  and  withdrawn  by  the  surgeon,  although 
they  need  not  be  when  buried  in  the  tissues,  for  they  become  encysted  or 
absorbed.  Sutures  of  silk  upon  the  surface  are,  however,  always  with- 
<irawn. 

The  forms  of  sutures  usually  employed  are  the  interrupted,  the  con- 
tinuous, and  the  twisted  or  pin  suture.  The  quill  suture  is  deservedly 
nearl}^  obsolete.  The  interrupted  suture  is  made  by  carrying  with  a 
needle  a  catgut,  silk,  wire,  or  wormgut  thread  across  the  wound,  cutting 
it  off  and  fastening  the  two  ends  by  tying,  twisting  or  clamping  with  per- 
forated shot.  This  is  repeated  at  intervals  along  the  wound.  The  twisted, 
or  pin  suture,  is  made  by  thrusting  a  steel  pin  through  the  lips  of  the 
wound,  which  are  then  held  in  apposition  by  a  silk  or  catgut  thread 
wrapped  around  the  ends  of  the  pin  and  across  the  surface  of  the  wound. 
The  pin  is  left  in  position  until  union  has  occurred.  The  thread  may  be 
twisted  about  the  pin  in  an  elliptical  or  figure  8  manner,  or  a  rubber  band 
may  be  employed  in  its  stead. 

Fig.  43.  Fig.  44 


Oranny  knot,  which  is  never  used  in  Flat  or  reef  knot.   (J.  D.  Bryant.) 

surgery.  (J.  I).  Betant.) 

Interrupted  sutures  are  best  made  with  catgut,  silk  or  flexible  iron-wire 
and  a  straight  needle.     Occasionally  a  curved  needle  may  be  preferable. 


138 


OPERATIVE    SURGERY 


In  linear  wounds  the  Hrst  suture  should  be  inserted  across  the  middle  ;  in 
irregular  wounds  the  projecting  points  had  better  be  approximated  first. 
The  needle  should  puncture  the  skin  not  nearer  than  about  one-eighth  to 
half  of  an  inch  from  the  margin  of  the  wound,  and  be  carried  deeply 
enough  to  bring  the  entire  depth  of  the  wound  surfaces  together. 


Fig.  4.5. 


First  tie  of  surgeon's  or  friction  knot.     The  second  tie  is  like  tliat  of  the 
flat  knot.      (J.  D.  Bryant.) 


Fig 


The  ends  of  the  suture  should  be  fastened  at  one  side  of  the  wound  by 
a  flat  or  reef  knot  if  silk  is  used,  by  a  surgical  knot  if  gut  is  employed,  by 
twisting  the  ends  or  clamping  them  with  shot  if  wire  is  employed. 

Sutures  should  be  placed  at  intervals  of  one-1'ourth  or  one-half  inch,  and 
should  never  be  applied  tightly,  since  mere  apposition  of  the  edges  is  all 
that  is  required  and  swelling  will  probably  increase 
the  tension.  Sutures  would  be  unnecessary  if  there 
was  in  wounds  no  gaping,  or  tendency  to  motion 
from  muscular  movements.  A  sufficient  number  of 
sutures  should  be  inserted  to  avoid  gaping  between 
them.  This  is  better  than  placing  them  far  apart 
and  using  adhesive  plaster  in  the  intervals,  since 
adhesive  can  scarcely  ever  be  sterile.  It  is  a  useless 
and  dangerous  agent  in  the  treatment  of  wounds. 
Three  to  six  days  is  long  enough,  as  a  rule,  for 
sutures  to  remain,  though  in  deep  wounds  and  in 
])Ositions  where  strain  is  liable  to  occur,  the  sutures, 
if  of  wire,  may  remain  almost  indefinitely.  When 
stitches  are  to  be  removed  the  wire  should  be  cut 
close  to  the  knot  or  twist,  the  long  end  bent  over  to 
the  other  puncture  and  the  wire  drawn  through  the 
tissues  in  a  curved  direction  by  means  of  a  forceps 
grasping  the  knot.  If  this  is  not  done,  a  little  hook 
of  wire  is  left  when  the  suture  is  cut,  and  pain  is  caused  by  drawing  this 
through  the  tissues.  Catgut  sutures  need  not  be  removed,  because  the 
portion  of  the  loop  buried  in  the  tissues  is  absorbed  and  the  external 
portion  finally  falls  away  from  the  .skin.  Chromicized  catgut  requires 
from  ten  to  thirty  days  to  be  absorbed  ;  ordinary  antiseptic  catgut  is 
absorbed  in  from  five  to  ten  days.  The  time  in  each  instance  depends 
largely  on  the  thickness  of  the  thread  of  gut.  Silk  sutures  may  be  cut 
and  withdrawn,  or,  if  entirely  buried,  may  be  allowed  to  remain  in  the 
tissues ;  when  they  are  either  absorbed  as  are  buried  gut  sutures  or  they 
become  encysted.  These  processes  only  occur  perfectly  when  the  sutures 
and  wound  are  free  from  germs. 

The  twisted,  pin,  or  hare-lip  suture  is  especially  serviceable  when  the 
wound  is  situated  in  movable  tissues,  as  about  the  face,  and  additional 
support  is  desirable,  and  also  where  considerable   hemorrhage  is  taking 


Interrupted  suture  of 
silk.showing  the  lower 
stitch  too  tightly  tied. 
(Stephen  Smith.) 


SUTUKES. 


139 


place  from  the  wound.  The  pins  must  be  inserted  rather  deeply,  carried 
transversely  across  the  wound  and  brought  out  through  the  opposite  edge 
of  skin.  The  thread  must  not  be  applied  too  tightly.  The  sharp  point 
of  the  pin  is  then  cut  off  or  guarded  by  a  piece  of  cork.  After  three  or 
four  days,  when  union  has  occurred,  the  head  of  the  pin  is  seized  with 
forceps,  the  pin  rotated  and  gently  withdrawn.  The  thread  is  often  left 
in  place  to  afford  support  until  it  falls  off  under  desiccating  influences 
about  the  wound.  A  combination  of  the  interrupted  and  twisted  suture 
is  sometimes  judicious  in  wounds  requiring  support  and  accurate  adjust- 
ment. 

Fig.  47. 


Twir^ted  or  piu  suture.     (Wyeth.) 

Continuous  differ  from  interrupted  sutures  in  that  the  first  stitch  is  taken 
near  the  end  of  the  w^ound  and  the  thread  carried  through  the  tissues 


Fig.  48. 


Fig.  49. 


Continuous  suture.  (Esmarch.) 

from  side  to  side  without  being 
cut  off  and  tied  every  time  it 
crosses  the  wound.  This  form 
of  suturing  is  used  a  good  deal 
more  now  than  in  the  days 
when  suppuration  of  wounds 
almost  constantly  occurred.  At 
that  time  and  under  those  cir- 
cumstances the  interrupted  su- 
ture was  convenient  because 
one  stitch  could  be  removed 
for  the  evacuation  of  any  pus 
which  formed  at  the  bottom 
of  the  wound  cavity.  Now  that 
we  have  little  fear  of  suppu- 
ration occurring  the  continuous 

suture  is  preferable  in  many  instances,  because  it  is  much  more  rapidly 
applied  than  the  interrupted  and  because  it  brings  the  edges  of  the  wound 


Showing  beginning  and  final  knot  of  continued 
suture. 


140  OPERATIVE    SURGERY. 

into  neater  apposition.  AVhcn  the  continuous  suture  is  begun  tlie  end  of 
the  thread  of  gut  is  tied  to  the  main  portion  of  the  thread  after  the  needle 
has  drawn  it  through  the  second  puncture.  The  needle  then  carries  the 
thread  across  the  wound  and  through  the  tissues  in  the  way  shown  by  the 
illustration.  The  suture  is  ended,  at  the  other  extremity  of  the  wound, 
by  tying  the  end  of  the  thread  and  the  loop  made  by  leaving  the  thread 
long  in  tlie  stitch  next  to  the  last.  This  method  is  shown  in  the  diagram. 
Buried  sutures  are  stitches  which  are  used  to  bring  together  tissues  at 
the  bottom  of  a  wound,  and  which  are  subsequently  entirely  covered  up 
by  more  superficial  layers  of  muscle  or  fascia,  or  by  skin.  In  closing 
large  and  deep  wounds  extending  through  different  i)lanes  of  muscle  the 
surgeon  should  suture  each  layer  of  muscle  and  each  layer  of  fjiscia  step 
by  step  from  the  bottom  to  the  surface.  This  hastens  union,  prevents  the 
formation  of  pockets  or  cavities  in  which  blood  or  Avound  secretions  might 
collect,  and  restores  most  effectually  the  normal  integrity  of  the  parts. 
Divided  nerve-trunks  should  be  united  by  these  buried  sutures,  severed 
tendons  accurately  approximated  and  muscular  masses  and  fascial  sheaths 
carefully  reconstructed.  Perfect  asepticism  is  essential  for  success;  cat- 
gut or  silk  sutures  are  to  be  employed  for  these  purposes.  In  suturing 
tendons  chromicized  gut  should  be  used,  because  ordinary  gut  is  apt  to 
be  absorbed  before  the  tendons  unite,  and  because  the  strain  upon  the 
suture  is  often  considerable.  In  all  these  instances  the  sutures  are  cut  off 
close  to  the  knots  and  are  allowed  to  become  absorbed  or  encysted.  The 
peculiar  method  of  passing  the  suture  shown  in  the  illustration  is  the  best 
for  tendons  ;  other  structures  may  be  united  by  the  interrupted  or  con- 
tinuous suture  as  seems  best  to  the  operator. 

Fig.  50. 


Diagram  of  suture  of  tendon.  (Esmarch.) 


The  peculiar  devices  used  for  suturing  intestinal  wounds  will  be  de- 
scribed under  Surgery  of  the  Abdomen. 

Dressings. 

The  dressing  which  practically  is  used  for  all  wounds,  whether  opera- 
tive or  accidental,  is  gauze.  This  gauze  is  what  is  technically  called 
in  trade  circles  cheese-cloth  or  butter-cloth.  It  is  a  loose  cotton  mate- 
rial with  open  meshes  and  readily  absorbs  fluids.  It  can  be  bought 
from  dealers  in  surgical  suj)plies,  either  ])lain  or  impregnated  with  cor- 
rosive sublimate  or  betanaphthol  in  varying  proportions,  and  is,  in  the 
latter  case,  properly  called  antiseptic  gauze.  Plain  gauze  is  supposed 
to  be  perfectly  free  from  germs,  which,  of  course,  it  never  is,  unless 
previously  subjected  to  high  heat  and  kept  in  cans  tightly  sealed.  Cheese- 
cloth can  also  be  readily  bought  at  dry  goods  stores,  and  after  it  has 
been  washed  in  hot  water  containing  a  little  soda  and  dried,  it  becomes 
a  very  cheap  and  effective  dressing.  This  the  surgeon  must  make  aseptic 
for  himself,  by  baking  it  in  an  oven  and  keeping  it- free  from  the  slightest 


DRESSINGS.  141 

possible  contamination  with  dust,  or  antiseptic  by  saturating  it  with  a 
germicide  solution. 

When  the  wounds  are  open  and  the  gauze  dressing  comes  in  actual 
contact  with  the  wound  surface  the  secretions  on  drying  glue  it  to  the 
wound.  A  great  deal  of  pain  is  therefore  given  to  the  patient  upon  the 
removal  of  such  a  dressing,  unless  it  has  been  carefully  soaked  for  some 
time  with  water,  which  must  be  sterilized  to  prevent  infection.  It  is 
well,  therefore,  to  cover  open  wounds  with  a  piece  of  thin  rubber  tissue  or 
oiled  silk  "  protective  "  before  applying  the  gauze  dressing.  If  rubber 
tissue  is  used  it  should  be  cut  full  of  slits  or  small  holes  with  a  pair  of 
scissors,  in  order  that  the  secretions  from  the  wound  may  escape  into  the 
gauze  and  not  macerate  the  tissues  lying  under  the  rubber  film.  Evap- 
oration and  percolation  are  more  free  through  the  oiled  silk,  which  goes 
by  the  name  of  "  protective,"  than  through  rubber  tissue,  hence  the 
former  does  not,  as  a  rule,  need  to  be  perforated.  If  a  wound  has  unfor- 
tunately become  the  seat  of  profuse  suppuration  the  gauze  will  not  adhere 
even  when  placed  in  direct  contact  with  it.  In  wounds  the  edges  of 
which  are  brought  into  actual  contact  by  sutures  there  is  no  occasion  for 
using  "protective"  under  the  gauze ;  the  gauze  may  then  be  laid  directly 
upon  the  wound  itself.  It  must  be  understood,  of  course,  that  this 
rubber  film  or  oiled  silk  must  be  thoroughly  cleansed  and  rendered  aseptic 
or  antiseptic  before  being  applied  to  the  wound.  It  is  perhaps  unneces- 
sary to  say  that  all  drainage-tubes,  whether  of  rubber  or  of  glass,  must 
in  a  similar  manner  be  rendered  aseptic  or  antiseptic  befoi'e  use. 

When  a  wound  is  dressed  a  large  mass  of  gauze  consisting  of  from  four 
to  twenty  layers,  varying  with  the  degree  of  serous  efl^usion  which  the  sur- 
geon presumes  will  escape  from  the  wound,  must  be  firmly  and  evenly 
bandaged  over  the  injured  surface.  It  is  absolutely  necessary  that  the 
margin  of  the  dressing  should  extend  a  considerable  distance  beyond  the 
limits  of  the  wound,  in  order  that  the  wound  secretions  may  not,  by  trav- 
elling between  the  skin  and  dressing,  get  beyond  the  edge  of  the  latter 
and  become  infected  with  bacteria  from  the  air,  clothing  or  bandages 
before  the  surgeon  repeats  his  visit.  In  such  an  event  the  organisms  will 
develop  in  the  bandages  or  portion  of  clothing  soiled  with  the  discharge 
and  cause  putrefaction  and  suppuration  ;  the  infection  will  continue 
along  the  path  of  serum  made  under  or  in  the  gauze,  and  finally  enter 
the  wound.  It  is  important,  therefore,  that  no  such  entrance  shall  be 
made  through  or  under  the  dressing  by  such  a  track  of  albuminous 
fluid  extending  to  infected  objects  outside.  The  bloody  serous  trans- 
udate, which  takes  place  from  the  wound,  usually  occurs  within  the  first 
few  hours.  It  is,  therefore,  wise  to  change  the  dressing  of  large  wounds 
and  of  wounds  where  there  has  been  a  gi-eat  deal  of  secretion,  within  the 
first  twenty-four  hours,  because  of  the  possibility  of  such  fluids  reaching 
the  surface  at  some  part  of  the  dressing  not  easily  examined  by  the  sur- 
geon. This  second  dressing  will  cause  no  annoyance  or  harm  if  it  is  done 
with  the  same  attention  to  antiseptic  precautions  as  is  given  to  the  first 
dressing.  The  hands  of  the  surgeon  and  all  instruments  and  dressings 
must  be  as  carefully  free  from  germs  as  at  the  time  of  the  operation. 
After  the  second  dressing  no  change  is  required  until  the  fluid  soaks 
through  the  gauze  in  the  course  of  several  days,  or  until  pain  in  the 
wound  or  a  marked  rise  in  the  temperature  of  the  patient  shows  that 
some  complication  has  arisen,  and  that  the  wound  is  not  doing  well.  The 
drainage-tubes  may  often  be  removed  at  the  time  of  the  second  dressing, 
unless  suppuration  has  occurred,  which  condition,  however,  we  do  not 


142  OPERATIVE    SURGERY. 

look  for  in  aseptic  wouuds.  *lf  suppuration  from  any  cause  does  exist 
in  a  wound  tubes  will  be  required,  to  give  free  vent  to  the  pus. 

In  small  wounds  where  thei'e  is  but  little  effusion  a  single  dressing  is 
often  sufficient,  and  by  the  second  or  third  day  the  wound  will  frequently 
be  found  cicatrized.  This  sometimes  occurs  at  the  second  dressing  of 
quite  large  wounds  when  tha\  dressing  is  not  made  for  two  or  three 
weeks. 

In  my  opinion  the  gauze  shouhuuways  be  applied  dry,  becau.se  bacteria 
are  much  less  liable  to  multiply  in  dry  situations  than  in  wet  ones;  hence 
a  wet  dressing  seems  to  me  to  increase  the  jjossibility  of  microbic  infec- 
tion, even  when  these  dressings  have  been  moistened  with  antiseptic  solu- 
tions. I  prefer  gauze  which  has  been  mad('Jisej)tic  by  baking,  applied 
dry,  or  gauze  which  has  been  impregnated  WTth  sublimate  solution  and 
subsequently  dried.  Gauze  which  has  been  sterilized  by  baking  is  not 
very  absorbent.  A  small  amount  of  glycerine  sprinkled  upon  it  before 
it  is  baked  makes  it  absorb  Huids  much  mor^fficiently. 

When  there  is  no  wound  and  a  poultice  is  desired  to  relieve  pain  it 
should  be  made  of  aseptic  or  antiseptic  gauze*  covered  with  oiled  silk  or 
rubber  cloth  to  ])revent  evaporation.  Poultices  of  flaxseed  and  similar 
material,  are  seldom  used  or  desirable. 

In  some  small  incised  wounds  a  dressing  of  collodion  and  iodoform,  or 
collodion  and  boric  acid  maybe  used  instead  of  a  gauze  dressing ;  for 
example,  after  the  removal  of  a  small  tumor  of  the  face  a  little  collodion 
mixed  with  iodoform  may  be  painted  over  the  edges  of  the  wound  in  such 
a  way  as  to  make  an  impervious  varnish,  which  keeps  the  wound  free 
from  germs.  Sometimes  this  collodion  dressing  can  be  made  a  little 
stronger  by  laying  a  small  portion  of  aseptic  absorbent  cotton  upon  the 
wound  and  saturating  it  with  collodion  and  iodoform  or  with  collodion 
alone.  Boric  acid  or  corrosive  sublimate  would  probably  answer  as  well 
as  iodoform  to  mix  with  the  collodion  and  would  be  less  obnoxious  in  odor. 
The  mixture  is  ])ainted  upon  the  part  after  the  catgut  sutures  have  been 
used.  If  corrosive  sublimate  is  selected,  not  more  than  an  eighth  or  a 
quarter  of  a  grain  should  be  mixed  with  a  fluidounce  of  collodion. 

Bandages. 

Roller  bandages  are  used  by  the  surgeon  for  the  purpo.se  of  retaining 
dressings  in  position,  making  pressure,  and  restraining  motion.  A  bandage 
is  a  strip  of  mu.slin,  linen,  or  flannel,  varying  in  width  from  one-half  inch 
to  two  or  three  inches  and  in  length  from  three  to  ten  yards.  It  is  ap- 
plied smoothly  to  the  surface  by  circular,  spiral,  and  reverse  turns,  and 
should  always  make  equable  pressure  and  be  firmly  enough  applied  to 
its  place  during  the  ordinary  movements  allowed  the  patient. 

When  a  considerable  amount  of  elastic  pressure  is  required  for  pro- 
moting absorption,  as  in  treating  diseased  joints  and  chronic  ulcers,  a 
bandage  made  of  pure  rubber  is  invaluable,  though  a  flannel  bandage 
will  in  some  degree  effect  the  purpose. 

The  P^smarch  apparatus,  which  consists  of  a  rubber  bandage  for  expel- 
ling blood  from  a  limb  and  a  rubber  tourniquet  for  preventing  its  return 
during  the  time  of  operation,  will  be  discussed  under  Diseases  and  In- 
juries of  Bloodvessels,  where  hemorrhage  is  considered. 


ABSTRACTION    OF    BLOOD. 


143 


Counter-irritation. 

When  a  mild  form  of  counter-irritation  is  wanted,  mustard  plasters, 
tincture  of  iodine,  water  of  ammonia,  and  similar  agents,  or  dry  cups,  are 
applied  to  the  skin ;  if  vesication  or  blistering  is  desirable,  cantharidal 
collodion,  cantharidal  citrate,  or  an  iron  disk  heated  by  immersion  in  hot 
water  is  employed.  More  powerful  revulsive  agents  are  setons,  caustic 
potassa,  and  the  red-hot  iron.  The  best  form  of  actual  cautery  is  the 
thermo-cauter}^  of  Paquelin,  which  consists  of  a  double  metal  tube  with 
a  hollow  platinum  end  through  which  a  current  of  benzole  vapor  is  blown 
by  compressing  a  rubber  bulb.  If  the  platinum  portion  is  first  moder- 
ately heated  in  a  lamp,  it  can  be  raised  to  and  maintained  at  a  red  or 
white  heat  by  keeping  a  constant  current  of  benzole  vapor  circulating 
within  it. 

Fig.  51. 


Paquelin's  thermo-cautery. 

This  is  an  exceedingly  convenient  and  manageable  instrument.  Ordi- 
nary cautery  or  soldering  irons,  heated  in  a  furnace,  answer  the  same 
purpose.  The  electro-cautery  is  usually  inconvenient  for  the  surgeon's 
use.  The  pain  felt  from  the  cauterization  after  the  patient  recovers  from 
anaesthesia  can  be  averted  by  painting  the  burned  surfaces  with  undiluted 
carbolic  acid  before  sensibility  is  regained. 

Counter-irritation  is  sometimes  obtained  by  thrusting  needles  into  the 
tissues — a  method  termed  acupuncture.  The  needles  may  be  arranged  in 
a  bundle  and  propelled  by  a  spring,  or  may  be  introduced  singly  by  the 
fingers  of  the  surgeon.  Additional  irritation  is  induced,  when  necessary, 
by  dipping  the  points  in  crotou  oil. 

Abstraction  of  Blood. 

Local  abstraction  of  blood  by  leeches  has  been  superseded,  to  a  great 
extent,  by  multiple  punctures  and  scarifications  with  a  sharp  knife  and 
by  wet  cupping.     In  both  cases  the  flow  of  blood  is  encouraged  by  aflEu- 


144  OPERATIVE    SURGERY. 

sions  of  hot  water.  General  bloodletting  is  accomplished  by  opening  a 
vein,  usually  at  the  bend  of  the  elbow,  or,  when  a  sudden  and  powerful 
inipressicni  is  required,  by  incising  the  temporal  or  radial  artery. 

When  venesection  from  the  arm  is  to  be  performed,  a  bandage  is  tied 
around  the  arm  above  the  elbow,  sufficiently  tight  to  prevent  the 
venous  return  but  not  firm  enough  to  prevent  the  downward  arterial 
flow.  The  veins  then  become  distended.  The  arm  must  next  be  made 
aseptic,  after  which  the  operator,  selecting  the  median  cephalic  vein  be- 
cause it  is  not  in  close  relation  with  the  brachial  artery,  steadies  it  with 
the  thumb  and  forefinger  of  his  left  hand,  and  makes  an  oblique  incision 
into  it  by  transfixing  it  with  the  point  of  a  bistoury.  The  incision  must 
be  a  free  one  to  allow  the  blood  to  escape  in  a  jet.  If  the  median  cephalic 
vein  is  not  large  enough  to  give  a  good  flow,  the  median  basilic  or  any 
one  that  is  prominent  may  be  selected.  It  must  be  remend)t'red  that  the 
brachial  artery  lies  under  the  median  basilic  vein;  but  if  the  vein  is 
transfixed  laterally  with  the  point  of  a  knife  and  the  incision  made  from 
within  outward,  there  is  no  danger  of  wounding  the  artery.  The  old- 
fashioned  spring  lancet  is  much  more  dangerous,  and  is  inferior  to  an 
ordinary  bistoury  for  such  an  operation.  The  vein  can  be  nicely  steadied 
for  the  incision  by  passing  a  small  acupressure  or  harelip  pin  through  the 
skin  and  underneath  the  vessel.  This  is  better  than  attempting  to  pre- 
vent its  slipping  away  from  the  bistoury  by  means  of  the  fingers. 

Phlebotomy  should  be  done  when  the  patient  is  in  the  semi-recumbent 
position.  Removal  of  the  bandage  around  the  arm  will  stop  the  flow  of 
blood,  after  which  an  antiseptic  pad  is  placed  over  the  wound  and  the 
limb  kept  comparatively  quiet  for  a  day  or  two. 

Arteriotomy  is  performed  by  merely  cutting  down  upon  the  pulsating 
vessel  and  making  an  oblique  or  traasver.se  incision  into  its  wall.  When 
the  amount  of  bleeding  is  satisfactory,  the  vessel  should  be  completely 
divided  and  pressure  applied  ;  or  ligatures  may  be  put  upon  the  ends  of 
the  artery. 

Aspiration  and  Tapping. 

Aspiration  is  the  evacuation  of  fluids  by  means  of  a  vacuum  connected 
with  a  hollow  needle  or  a  canula,  and  is  advantageous  because  it  prevents 
the  admission  of  air  to  the  cavity  from  which  the  fluid  is  taken.  Hence 
septic  changes  are  avoided.  The  aspirator,  as  perfected  by  Potain,  con- 
sists essentially  of  a  reservoir  which  is  connected  with  an  exhausting 
pump  and  from  which  a  tube  passes  to  be  connected  with  a  hollow  needle 
or  a  canula  and  trocar.  8top-cocks  are  provided  to  prevent  the  admis- 
sion of  air  to  the  tubes  and  reservoir  or  to  the  cavity  to  be  tapped. 

When  an  abscess  or  serous  collection  is  to  be  aspirated,  a  vacuum  is 
created  in  the  reservoir  with  the  air-pump,  and  the  needle  introduced 
into  the  tissues.  The  vacuum  chamber  is  then  connected  with  the  needle 
by  turning  a  stop  cock,  and  as  soon  as  the  point  of  the  needle  enters  the 
cavity  atmospheric  pressure  forces  the  fluid  into  the  chamber. 

When  an  aspirator  is  not  at  hand,  or  when  it  is  desirable  to  have  less 
pressure  than  that  induced  by  a  vacuum,  the  principle  of  the  siphon  may 
be  utilized  by  attaching  a  long  tube  to  a  trocar  or  hollow  needle  and 
carrying  the  end  below  the  level  of  the  patient. 

The  hypodermatic  syringe  answers  admirably  for  aspirating  small  cysts 
and  abscesses,  and  is  also  of  great  value  in  determining  the  character  of 
obscure  swellings.     The  grooved  exploring  needle,  so  frequently  used,  is 


ASPIRATION    AND    TAPPING, 


145 


far  inferior  to  the  hollow  needle  and  syringe,  and  is  never  used  by  me  for 
diagnostic  purposes.  Motion  of  the  end  of  the  hypodermic  needle  will 
often  disclose  a  cavity,  even  if  the  contents  are  too  viscid  to  escape  through 
the  orifice  into  the  glass  barrel  of  the  hypodermic  syringe. 


Fig.  52. 


Aspirator. 

When  the  entrance  of  air  into  the  cavity  to  be  evacuated  is  considered 
unimportant  a  trocar  and  canula  are  employed.  In  using  a  trocar  the 
surgeon  should  make  the  parts  tense  by  pressure  with  the  fingers  of  the 
left  hand,  select  a  point  free  from  veins  or  arteries  and  plunge  the  trocar 
and  its  surrounding  canula  through  the  skin  with  a  sudden  rotary 
thrust.  As  long  as  fluid  flows  freely  enough  to  fill  the  entire  calibre  of 
the  canula  no  air  will  enter.  Such  a  free  flow  can  be  kept  up  until  the 
sac  is  nearly  empty  if  pressure  is  made  upon  its  walls  by  the  surgeon's 
fingers. 

In  many  instances  open  aseptic  incision  is  preferable  to  either  aspira- 
tion or  tapping,  which  are  too  often  the  resources  of  a  timid  and  dilatory 
surgery.     They  have,  however,  a  legitimate  field. 


10 


CHAPTER   Xll. 

PLASTIC  OR   REPARATIVE  SURGERY. 

Under  the  term  plastic  surgery  are  grouped  those  operations  which 
have  for  their  object  tlie  construction  of  absent  parts,  usually  from  the 
patient's  own  tissues,  and  the  reposition  or  curtailment  of  parts  displaced 
or  deformed  by  accident  or  disease. 

The  word  plasty  is  often  used  with  a  prefix  to  indicate  the  organ 
formed  ;  thus,  rhinoplasty  means  the  reconstruction  of  a  nose,  cheilo- 
plasty  the  formation  of  a  lip. 

Plastic  surgery  is  called  into  play  to  overcome  both  congenital  and 
acquired  defects  and  deformities.  Its  objects,  therefore,  may  be  stated  to 
be  :  To  correct  deformity  due  to  imperfect  foetal  development,  as  harelip 
and  clefl  palate ;  to  replace  i)arts  lost  or  deformed  by  injury  or  ulcera- 
tion, as  in  closing  fistules  or  clefts,  and  reconstructing  destroyed  noses  or 
lips  ;  to  relieve  or  prevent  distortion  from  cicatricial  contraction,  as  after 
burns  and  cervical  abscesses  and  the  removal  of  tumors  requiring  abla- 
tion of  a  large  amount  of  integument;  and  to  curtail  organs  rendered 
unseemly  by  abnormal  growth,  as  in  greatly  hypertrophied  nose  or 
tongue,  and  in  large  and  protruding  ears. 

The  structures  used  in  constructive  operations  are  especialh'  skin  and 
subcutaneous  cellular  tissue,  though  raucous  membrane,  which  becomes 
somewhat  like  skin  when  removed  to  the  external  surface,  muscle,  peri- 
osteum, and  even  bone,  are  at  times  successfully  utilized. 

The  steps  of  a  plastic  operation  are  to  be  followed  in  regular  succession 
and  the  plan  of  procedure  should  be  clearly  fixed  in  the  operator's  mind 
before  he  makes  the  first  incision. 

The  patient  must  be  in  good  health,  so  as  to  be  less  likely  to  have 
erysipelas  or  ulcerative  action  attack  the  wounds  made.  When  parts 
destroyed  by  syphilis  are  about  to  be  reconstructed,  it  must  be  ascer- 
tained that  no  syphilitic  manifestations  have  occurred  for  several  months, 
since  a  recurrence  of  specific  ulceration  would  destroy  the  success  of  the 
plastic  operation  and  perhaps  render  future  measures  impossible.  The 
operation  should  be  rigidly  aseptic. 

The  successive  steps  are  :  Freshening  the  edges  of  the  vacuity  to  be  filled 
and  obtaining  one  or  more  flaps  if  such  are  required ;  arresting  all 
bleeding,  since  clots  between  the  raw  surfaces  may  prevent  union  by  first 
intention;  adjusting  the  parts  in  proper  relation  without  tension  and 
retaining  them  in  apposition  by  sutures ;  closing  the  gap  left  by  removal 
of  the  flaps,  if  such  have  been  employed  ;  dressing  all  the  wounds  anti- 
septically  or  aseptically,  and  preventing  motion  and  frequent  handling  of 
the  paits. 

In  complicated  reparative  procedures  it  is  often  necessary  to  accom- 
plish the  desired  end  by  a  series  of  operations,  each  one  of  which  effects 
a  result  which  affords  a  ba.<is  for  subsequent  measures.  The  time  between 
any  two  operations  may  be  weeks  or  months,  for  the  secondary  operation 
should  not  be  undertaken  until  cicatrization  and  shrinkage  have  fully 
determined  the  condition  gained  by  the  primary  one. 


METHODS    USED    IN    PLASTIC    SURGERY.  147 

Sutures  of  catgut,  plain  or  chromicized,  of  silk,  and  of  wire  are  used 
according  to  the  length  of  time  their  sustaining  power  is  needed.  In 
applying  the  sutures,  doubling  in  of  the  edges  of  the  flaps  can  be  pre- 
vented by  introducing  the  needle  obliquely,  so  that  the  punctures  on  the 
inner  surface  are  further  from  the  mai-gin  than  the  external  punctures. 
This  causes  the  apposed  sides  to  pout  out  a  little  at  first,  but  the  protru- 
sion disappears  with  cicatrization  ;  if  not,  it  can  be  pared  away  subse- 
quently. A  few  deeply  placed  sustaining  sutures  may  be  advantageous 
in  maintaining  approximation  when  the  plastic  operation  requires  the 
union  of  large  surfaces  extending  inward  to  a  considerable  depth,  or 
buried  sutures  may  be  employed.  The  strain  is  thus  taken  from  the 
superficial  sutures,  and  rapid  union  of  all  portions  of  the  wound  is 
encouraged.  Sometimes  the  support  given  by  the  pin  suture  makes  it 
preferable  to  the  interrupted  or  continuous  sutures.  Silk  or  gut  sutures 
are  sometimes  employed  between  metallic  ones  to  make  very  accurate 
apposition  of  thin  edges.  Their  early  removal  or  absorption,  before  it  is 
safe  to  take  out  the  deeper  metallic  sutures  is  not  disadvantageous. 

The  tongue-and-groove  sutures'  of  Dr.  Joseph  Pancoast  is  often  a  very 
excellent  method  of  maintaining  apposition  in  rhinoplasty  and  operations 
for  exstrophy  of  the  bladder.  It  consists  in 
slipping  the   flap   margin,   which  has   been  Fig.  53. 

bevelled,  into  a  groove  made  by  dissecting  up 
the  edge  of  skin  surrounding  the  raw  surface 
to  be  covered. 

Four  raw  surfaces  are  thus  apposed.    Wire 

or  silk  sutures  are  then  applied,  as  shown  in 

the  diagram,  and  fastened  over  a  perforated  y 

disk  or  a  pad.    It  is  easy  to  adjust  the  sutures     Diagram  of  tongue  and  groove 

by  having  both  ends  armed  with  needles.  suture. 

The  gap  left  by  the  removal  of  the  flap  in 
plastic  operations  should  be  closed,  if  possible,  by  drawing  the  integument 
together,  or  by  inserting  a  flap  taken  from  the  neighboring  skin  if  it  can 
be  obtained  from  a  site  which  will  put  the  cicatricial  tension  in  a  less 
objectionable  locality.  If  neither  means  is  applicable  provision  should 
be  made  for  healing  by  granulation.  Often  the  tissue  dissected  away 
to  make  a  raw  surface  for  adhesion  of  the  flap  can  be  utilized  for  closing 
the  hiatus  left  by  the  elevation  of  that  flap. 

The  various  plastic  procedures  are  included  in  the  three  methods  of 
operating  which  I  shall  term  respectively  the  methods  by  displacement, 
by  interpolation,  and  by  retrenchment.  Under  the  displacement  method 
are  included  operations  done  by  simple  approximation  and  by  sliding  ; 
under  the  method  of  interpolation  are  classed  procedures  accomplished 
by  transference  and  by  transplantation. 

The  relations  and  characteristics  of  these  modes  of  operating  will  be 
seen  by  the  schedule. 

Methods  used  in  Plastic  Surgery. 

DisPLACEMEMT — stretching  or  sliding  of  tissues. 

I.  Simple  apjjroximation  after  freahening  the  edges.  a,a  in  harelip,  vesioo-vaginal  fistule, 

and  notches  caused  by  tearing  out  ear-rings. 
II.  Sliding  into  position  after  transferring  tension  to  adjoining  localities.  a.s  in  V-shaped 
incision  for  ectropium   and  cicatricial  contraction  of  joints  after  burns,  and  in 
linear  incisions  to  allow  stretching  of  skin  to  cover  large  wounds  and  to  relax 
contracted  parts. 


148  PLASTIC    OR    RETARATIVE    SURGERY. 

Interpolation' — bormwiiig  material  from  arljacetit  resiions,  from  a  limb,  or  from  another 
person. 
I.   Tranfiffrrinii  tiap  with  a  pedicle} 

A.  Putting  in  place  at  once. 

1.  By  rotating  Hap  on  the  peilicle   in    it?  own   plane  through  one-fourth  or 

one-half  a  i-in-le,  as  in  making  upper  eyelid  or  nose  from  forehead. 

2.  By  twisting  llap  on  its  pi-dicle,  as  in  making  side  of  nose  from  lip. 

'A.  By  everting  Hap  entirely  so  that  raw  surface  is  uppermost,  as  in  covering 
exstrophy  of  bladder  t>y  a  scrotal  Hap. 

4.  Supcrim])osing  one  Hap  on  another  which  has  been  everted.    This  is  done 

where  a  thick  wall  is  desirable,  as  in  closing  the  front  of  an  exstrophy 
of  the  bladder. 

5.  By  jumping,  or  carrj'ing  flap  across  a  bridge  of  skin,  and  fixing  only  its 

end  to  the  part  to  be  repaired.  When  the  Hap  has  become  attached  the 
pedicle  is  severed.     This  manceuvre  is  rarely  employe<l. 

B.  Putting  in  place  gradually  by  successive  migrations,  by  same  manoeuvres  as 

when  the  flap  is  placed  at  once  in  its  permanent  position. 

This  method  is  not  very  commonly  needed,  but  may  be  valuable  when 
there  is  nothing  but  cicatricial  material  in  the  immediate  vicinity  of  the 
part  to  l)e  repaired. 
II,   Transphiiifitiff  iciihont  a  pedicle. 

a.  By  carefully  suturing  or  fixing  in  the  gap  areas  of  tissue  recently  dissected 

from  distant  regions,  or  taken  from  the  lower  animals;  such  as  re- 
placing the  bone  button  after  trephining,  inserting  portions  of  nerve- 
trunks  in  wounded  nerves,  etc. 

b.  By   skin-grafting  with    small   pieces  or    large  shavings  of    skin.      This   is' 

the  manoeuvre  of  this  class  that  has  been  followed  by  the  greatest 
success.  As  it  les.sens  cicatricial  contraction  it  may  be  advantageously 
used  at  times  in  plastic  operations  that  necessarily  leave  surfaces  to  heal 
by  granulation.     Skin  from  the  frog's  abdomen  may  answer  well. 

c.  By  readjusting  finger-tips,  ears,  and  noses  recently  completely  severed  by 

injuries. 
Retren'Chmext — removing  superfluous  material  and  causing  cicatricial  contraction, 

I.  By  cutting  out  elliptical  or  semi-elliptical  pieces  of  tissue,  as  in  ptosis,  cystocele, 
and  prolapse  of  the  rectum. 
II.  By  cutting  out  trians;ular  or  wedge-shaped   portions  of  tissue,  as  in  closing  the 
vaginal  aperture,  decreasing  the  size  of  a  lip,  ciir,  or  nose,  and  separating 
webbed  fingers. 

Retrenchment  is  often  valuable  because  it  decreases  the  relative  size  of 
features;  thus,  if  a  nose  has  been  partially  lost  the  upper  lip  appears  too 
large,  and  its  diminution  will  render  the  deficient  nose  le-ss  noticeable. 
When  material  is  taken  from  the  prominent  feature,  and  especially  if 
added  to  the  other  the  normal  proportion  is  nearly  reestablished  and  de- 
formity greatly  concealed. 

To  secure  success  in  plastic  devices  certain  precautions  should  be 
observed.  In  the  first  place,  the  patient  should  be  in  good  general  health 
and  free  from  irritation  or  inflammation  about  the  seat  of  the  proposed 
operation.  In  transferring  or  transplanting  it  is  essential  to  select  normal 
integument  for  the  flap,  because  cicatricial  tissue  is  almost  sure  to  slough 
if  dissected  irom  the  .subjacent  structures.  Approximation  and  sliding 
operations,  however,  may  be  successfully  performed  with  cicatricial  tissue, 
because  these  methods  interfere  very  little  with  the  vascular  supplv  from 
beneath. 

All  flaps  should  be  made  large,  thick,  and  with  a  good  va.scular  supply 
through  a  wide  pedicle.  As  soon  as  the  flap  is  dis.>^ected  loose,  it  shrinks 
and  becomes  paler  and  cooler.  Hence,  it  should  consist  of  skin  and 
plenty  of  subcutaneous  tissue,  because  thick  flaps  contract  less  and  are 
more  vascular.     It  should  be  made  about  one-third  larger  in  area  than 

1  When  a  flap  is  borrowed  from  the  arm  or  hand  there  is  less  necessity  for  rotating  and 
twisting  than  when  it  is  taken  from  the  neighborhood  of  the  organ  to  be  constructed. 
The  latter  is  generally  the  preferred  method,  however,  because  less  irksome  to  the  patient 
than  the  former  with  its  constrained  posture. 


METHODS    USED    IN     PLASTIC    SURGERY.  149 

the  space  to  be  filled  and  should  be  allowed  to  cool  as  little  as  possible  by 
being  placed  in  position  as  quickly  as  practicable.  For  the  last  two 
reasons  I  consider  it  preferable  to  freshen  the  edges  of  the  part  to  be 
repaired  before  making  the  flap.  This  is  especially  true  in  transplanting 
flaps. 

It  is  sometimes  well  to  cut  a  diagram  of  the  flap  out  of  paper  or  cloth, 
and  mark  a  similar  outline  upon  the  skin  with  ink  before  beginning  the 
dissection  of  the  flap.  It  must  be  remembered  that  when  the  flap  is 
formed  it  contracts  very  much.  At  the  same  time  the  gap  from  which  it 
was  taken  appears  larger  than  is  really  the  fact  because  of  retraction  of 
the  margins  of  the  wound.  Xevertheless,  it  is  well  to  make  the  flap  at 
least  one-third  larger  and  much  thicker  than  the  space  into  which  it  is  to 
be  interpolated  would  seem  to  require,  since  the  flap  shrinks  at  once  and 
undergoes  contraction  and  absorption  from  cicatricial  changes  for  many 
weeks  after  union  has  occurred.  Any  redundancy  can  be  readily  re- 
moved when  lapse  of  time  proves  it  actually  to  exist. 

To  guard  against  imperfect  nutrition  and  consequent  sloughing  of  the 
flap,  it  is  well  to  make  it  with  its-  long  axis  corresponding  with  the  direc- 
tion of  arterial  supply,  and  its  base  presenting  toward  the  cardiac  portion 
of  the  arteries.  Where  there  is  very  free  anastomosis,  as  upon  the  face, 
this  rule  may  be  disregarded  to  a  considerable  extent.  The  calibre  of 
the  supplying  vessels  must  not  be  interfered  with  by  too  much  twisting  or 
tension  of  the  pedicle,  which  must  always  be  wide  and  thick.  Injurious 
tension  on  the  pedicle  can  frequently  be  prevented  by  cutting  a  pedicle  with 
curved  margins,  which  will  allow  increased  stretching  without  occluding 
the  vessels.  .Skin  free  from  hairs  should  be  selected  when  possible,  unless 
it  is  desired  to  make  eyebrows. 

A  gap  to  be  filled  by  interpolation  and  parts  to  be  united  by  approx- 
imation should  have  their  surfaces  prepared  by  such  free  incisions  as  will 
give  abundant  areas  of  contact  for  union  by  first  intention.  It  is  an  error 
to  pare  away  so  little  tissue  that  only  a  thin  raw  edge  is  obtained.  It  is 
necessary  to  have  broad  surfaces  of  contact  to  make  successful  plastic 
operations,  and  these  must  be  obtained  even  at  the  sacrifice  of  consider- 
able material.  The  additional  material  removed  will  not  be  so  great  but 
that  it  can  be  supplied  during  the  subsequent  steps  of  the  operation. 

Operations  for  harelip  and  torn  perineum  are  often  imperfect  because 
of  neglect  of  this  rule. 

When  all  hemorrhage  from  the  flaps  and  freshened  edges  has  been  con- 
trolled, accurate  approximation  is  to  be  made  by  numerous  sutures,  which 
should  hold  the  parts  merely  in  contact,  allowing  them  to  lie  loosely  and 
without  tension.  It  is  important  in  constructing  new  noses  and  other 
features  to  be  satisfied  at  first  with  obtaining  a  bulky  semblance  of  the 
organ,  and  not  to  endeavor  to  trim  down  the  structures  to  an  accurate 
conformation,  because  it  is  impossible  to  estimate  the  amount  and  char- 
acter of  cicatricial  shrinkage  which  will  inevitably  occur. 

Exudation  and  organization  of  lymph  sufficient  to  hold  the  parts  to- 
gether with  moderate  firmness  occurs  in  from  two  to  three  days ;  then 
some  or  all  of  the  sutures  may  usually  be  removed.  Metallic  sutures 
cause  so  little  local  irritation  that  they  may  be  allowed  to  remain  as  long 
as  there  is  any  danger  of  disruption  of  the  adhering  parts.  The  silk 
sutures,  which  are  often  useful  in  securing  accurate  adjustment  at  the 
very  edges  of  the  wounds,  are  generally  removed  early.  Gut  sutures 
may  be  allowed  to  remain  until  they  fall  off'  from  absorption  of  the  por- 
tion lying  in  the  tissues.     Absolute  antisepsis  adds  greatly  to  the  success 


150 


PLASTIC    OR     REPARATIVE    SURGERY. 


of  plastic  operations,  luid  causes  healing;  with    the  iniiiiimun  deu'ree  ol 
scarring. 

In  transplanting  without  a  pedicle,  it  is  of  the  utmost  importance  that 
the  tissues  be  kept  absolutely  aseptic  and  warm.  Disks  of  bone,  pieces 
of  nerve,  skin  sluivings,  and  such  tissues,  when  to  be  thus  used,  should  be 
kept  warm  in  sterilized  water  of  about  105°  F.  If  antiseptic  solutions 
are  employed,  they  should  be  weak  and  unirritating. 

Tiie  success  following  well  devised  and  carefully  performed  ])lastic 
operations  is  very  gratifying.  It  is  especially  so  in  cosmetic  operations, 
since  the  improved  apjiearance,  though  not  erpial  to  the  normal  condition, 
is  of  great  solace  to  the  disfigured  patient.  It  is  always  a  long  time  be- 
fore the  cicatrices  become  white  and  soft;  therefore  the  full  result  is. not 
apparent  until  many  months  have  elapsed.  The  scars  always  remain 
visible,  however;  hence  the  illustrations  of  many  published  cases  are 
deceptive  in  the  apparent  absence  of  scarring. 

The  disabilities  due  to  iistules,  ruptured  perineum,  and  many  other 
conditions,  can  often  be  entirely  removed  by  plastic  surgery.  If  gangrene 
of  the  flap  does  not  occur  before  the  end  of  the  fourth  day  it  is  not  likely 
to  take  place,  and  the  integrity  of  the  operation  is  pretty  well  assured. 
If,  however,  during  the  first  three  or  four  days  the  flap  becomes  grayish 
and  pulpy,  and  shows  a  loosened  cuticle,  or,  on  the  other  hand,  if  it 
assumes  a  dry  and  withered  aj^pearance,  it  is  evident  that  destruction  by 
sloughing  of  more  or  less  tissue  is  supervening.  The  surgeon  should, 
nevertheless,  leave  the  parts  in  position,  kee])  them  warm,  and  disturb  the 
dressings  as  little  as  possible,  because  the  gangrene  may  involve  only  the 
edges  or  the  superficial  layers  of  the  flaps.  A  small  amount  of  living 
tissue  remaining  after  the  limitation  of  the  sloughing  process  will  often  be 
very  serviceable  in  making  the  operation  entirely,  or  at  least  iiartially. 
successful. 

Fig.  5-1. 


Fig.  55. 


Plastic  operation  by  V-shaped  flap  to 
correct  eversion  of  lower  eyelid. 


Plastic  operation  by  V-shaped  flap. 
Sutures  applied.     (Stei.i.wag.) 


To  illustrate  the  manner  of  doing  plastic  operations,  I  shall  describe  a 
few  of  the  plans  that  will  be  found  useful.  As  every  case  has  peculiari- 
ties of  its  own,  the  illustrations  are  given  merely  as  types  which  will 
prove  suggestive. 


METHODS    USED    INT    PLASTIC    SURGERY. 


151 


Harelip,  as  will  be  shown  in  another  part  of  this  treatise,  is  usually 
remedied  by  paring  the  edges  of  the  cleft  and  approximating  the  fresh- 
ened surfaces  with  the  pin  suture.     Ectropium,  or  eversion  of  the  lower 
eyelid  from  cicatricial  contraction,  is   greatly  improved  by  making   a 
V-shaped  incision  downward,  with  its  base  embracing  the  everted  section 
of  the  lid,  and  dissecting  the  tense  structures  from  the  adjacent  muscles 
so  that  the  V-shaped  area  of  the  skin  can  be  slid  upward  until  the^lid 
assumes  its  natural  position.    This  re- 
lieves the  downward  tension  without  Fig.  56. 
materially  disturbing  the  blood-supply 
of    the   somewhat    poorly   nourished 
cicatricial  tissue.    The  gaping  wound 
left  below  and  laterally  can  usually 
be  closed  by  stretching  the  skin  or 
by  interpolating  flaps. 

This  principle  of  relieving  tension 
can  be  utilized  in  many  regions  after 
deformity  from  burns.  The  point  of 
the  V  must  always  be  in  the  line  of 
greatest  tension. 

Depressed  and  irregular  cicatrices, 
such  as  occur  in  the  neck  after  chronic 
suppuration  of  lymphatic  glands,  can 
be  rendered  more  sightly  by  carrying 
an  elliptical  incision  around  them, 
freeing  the  integument  laterally,  and 
drawing  the  under- cut  skin  over  the 
depression,  which  has  previously  been 
made  raw  by  abrasion. 

This  method  gets  rid  of  the  depres- 
sion and  leaves  a  linear  cicatrix.  It 
has  been  proposed  by  Mr.  Adams  to 
cut  loose  the  deep  attachments  of 
such  scars  with  a  tenotome,  and  then 
to  keep  the  scar  tissue  raised  for  a 
few  days  by  pins  inserted  beneath. 
Elevated  scars  can  be  excised  as 
tumors,  though  the  redundancy  some- 
times returns. 

Plastic  operations  for  reconstruct- 
ing the  nose  may  be  made  by  trans- 
ferring flaps  from  the  forehead,  or  from  the  arm  as  suggested  by 
Taliacotius.  The  septum,  or  at  least  the  columna,  can  be  well  made  out 
of  a  piece  cut  from  the  entire  thickness  of  the  upper  lip.  Portions  of  the 
nose  may  be  restored  by  flaps  from  the  cheeks  or  upper  lip.  It  is  well  to 
remember  that  taking  portions  of  the  lip  away  gives  a  flattened  nose  a 
more  marked  prominence  ;  hence,  two  indications  are  fulfilled  by  using 
labial  flaps  for  rhinoplastic  procedures.  The  parts  may  be  kept  in  place 
by  transfixing  the  organ  and  the  septum  with  pins,  or  tubes  or  plugs  may 
be  placed  in  the  nostrils  for  a  few  days.  When  the  bridge  is  very  much 
shrunken,  flaps  from  the  forehead  and  cheeks  may  be  superposed  to  give 
thickness.  The  lower  lip  can  be  repaired  by  flaps  from  the  chin  or 
cheeks,  from  the  upper  lip  if  the  loss  of  substance  is  near  the  angle  of 
the  mouth.     The  plastic  operations  by  which  crooked  noses  and  other 


Operation  for  depressed  scar,  a  shows 
lines  of  incision  around  depressed  scar, 
and  knife  separating  skin  from  under- 
lying tissues,  h.  Edges  sutured  after  being 
drawn  to  middle  line  over  depressed  tis- 
sues which  have  been  made  raw  bv  scrap- 


152 


PLASTIC    OR    REPARATIVE    SURGERY. 


deformed    features  are    improved   vary  with    the   character  of  the  dis- 
tortion.' 


Fig. 


Fic  58. 


Outline  of  flap  taken  from  forehead  fi»r  Outline  of  flap  taken  from  upper  lip  for 

reconstruction  of  nose.    (Bryant).  reconstruction  of  ala  of  nose. 

I'lG.  59. 


''-^>    \J    ^^^J 


7 
/ 
} 
•  i 

\ 

t  ^^ 

,^ 


Shows  outline  ot  flaps,  for   making  the 
nasal  bridge  higher.     (Stimson.) 

Fig.  00. 


Shows  the  frontal  flap  turned  down 
under  the  lateral  flajis.  The  raw  surface 
on  forehead  is  left  to  granulate.  (Stlmsos.) 

Fn;.  r,l. 


Plastic  operation  for  reconstructing  lower  lip.     (Erichsen.) 
'  See  author's  monograph  on  the  Cure  of  Crooked  and  Otherwise  Deformed  Noses. 


PART  II. 

SPECIAL   SURGICAL    PATHOLOGY,  OR  PRACTICE   OF 

SURGERY. 


CHAPTER    XIII. 

SURGERY   OF   SPECIAL  STRUCTURES. 

DISEASES   AND    INJURIES    OF    THE    SKIN   AND   ITS   APPENDAGES   AND   OF 
THE   SUBCUTANEOUS   TISSUE. 

The  cutaneous  eruptions  do  not  belong  to  the  domain  of  surgery,  and 
therefore  ■vvill  not  be  discussed  in  this  treatise.  Ulcers,  wounds  of  the 
soft  parts,  and  tumors  have  had  sufficient  attention  given  them  in  the 
preceding  chapters,  hence  no  further  reference  to  them  is  required  in  this 
connection. 

Wart  or  Verruca. 

Definition. — A  wart  is  a  circumscribed  hypertrophy  of  the  cutaneous 
papillae. 

Pathology. — It  is  in  fact  a  papilloma,  and  may  have  a  smooth  or  rough 
surface  according  to  the  arrangement  of  epithelium  covering  the  enlarged 
papilljB.  The  histology  of  papilloma  is  discussed  in  the  chapter  on 
tumors.  Warts  may  be  quite  hard  and  horny,  as  in  the  common  form 
found  on  the  hands,  moderately  soft,  as  seen  upon  the  backs  of  old 
persons,  or  very  soft  and  friable,  as  the  moist  verrucous  vegetations 
situated  upon  the  anal  and  genital  muco-cutaneous  surfaces.  The  last 
are  not  syphilitic,  but  depend  upon  an  irritation  due  to  muco-purulent 
discharges  of  any  kind.  The  discharge  may  be  venereal,  but  this  has 
nothing  to  do  with  its  causing  the  warts.  The  growths  are  very  vascular 
and  may  be  the  source  of  hemorrhages.  The  fetid  odor  is  due  to  decom- 
position of  the  secretions.  The  other  forms  are  not  very  vascular  and 
are  usually  darker  than  the  adjacent  skin.  Warts  on  mucous  membranes 
often  bleed  freely  and  in  the  bladder  and  urethra  may  cause  obstruction 
to  urination.  A  warty  growth  occurs  on  the  hands  of  those  engaged  in 
making  post-mortem  examinations,  as  a  result  of  irritation  from  the 
cadaveric  fluids. 

The  horny  wart  at  times  disappears  spontaneously,  hence  the  reputa- 
tion of  many  household  applications. 

Treatment.^ — Excision  with  scissors  or  curette  or  repeated  cauteriza- 
tion with  chromic  acid,  glacial  acetic  acid,  or  ethylate  of  sodium  is  the 
best  treatment.     A  mixture  of  salicylic  acid  (gr.  xxx),  extract  of  canna- 


]I54  SURGERY    OF    SPECIAL    STRUCTURES. 

bis  indica  (gr.  x),  and  collodion  (5J)  is  recommended  to  be  ap])lied 
daily.  After  a  few  days  the  devitalized  tissue  should  be  scraj)ed  off. 
Lijratiou  may  be  emi)loved  if  the  wart  is  pedunculated. 

The  soft  warts,  often  improperly  called  venereal  vegetations,  may  be 
treated  in  the  same  way,  though,  when  large,  provision  against  hemor- 
rhage must  be  made  by  the  surgeon  being  ready  to  apply  pressure  or 
astringents.  Powdered  tannic  acid  I  have  found  a  good  styptic  appli- 
cation. The  ccraseur  or  the  actual  cautery  may  be  used  for  removing 
very  large  masses  of  these  vegetations. 

Corn  ok  ('i>avus. 

Definition. — A  corn  is  a  small,  circumscribed,  cone-shaped  callosity, 
due  to  hypertrophy  of  the  epidermis,  usually  situated  upon  the  feet  or 
hands,  and  having  its  apex  pressing  upon  the  ]iajnllary  layer  of  the 
skin. 

Pathology. — A  corn  is  originally  a  j)ai)illoma  or  wart,  but  as  the 
epidermis  thickens  it  is  pressed  into  the  underlying  tissues  like  a  nail 
driven  into  a  board  and  the  iiapilhe  finally  atrophy. 

The  cause  of  corns  is  pressure,  of  misfitting  shoes  or  from  some  instru- 
ment used  in  manual  labor,  which  induces  chronic  inflammatory  hyper- 
plasia. 

The  pain  is  due  to  pressure  on  the  delicate  papillary  layer  of  the  true 
skin,  between  which  and  the  callosity  a  small  bursa  is  sometimes  developed. 
If  active  inflammation  and  suppuration  occur  beneath  the  corn,  the  pain 
is  intense,  because  the  pus  cannot  escape  through  the  thickened  epidermis. 

When  moisture  is  constantly  present,  as  between  the  toes,  the  corn  is 
macerated  and  is  called  a  soft  corn.  Pathologically  hard  and  soft  corns 
are  the  same.     A  hard  corn  is  occasionally  found  under  the  toenail. 

Treatment. — The  treatment  consists  in  removing  pressure  by  wearing 
broad-soled  shoes,  straight  along  the  inner  border,  with  low  heels.  The 
hardened  epidermis  may  be  scraped  or  cut  away.  This  is  best  done  per- 
iiaps  after  softening  the  epidermis  by  soaking  in  hot  water,  by  poultices, 
or  by  applications  of  alkaline  solutions,  such  as  sodium  carbonate  (gr.  x 
to  f  ,5J ).  In  using  strong  alkalies  care  should  be  exercised  not  to  touch 
surrounding  parts.  The  corn  may  be  surrounded  with  a  ring  of  wax. 
As  the  removal  of  the  horny  exterior  relieves  the  pressure  on  the  true 
skin,  pain  will  be  mitigated  by  these  measures.  A  thick  pad  or  plaster 
with  a  central  perforation  to  admit  the  callosity  will  palliate  pain  in  the 
same  way.  The  salicylic  acid  application  given  for  the  treatment  of  warts 
is  often  beneficial  in  cases  of  corns.  Strong  applications  of  nitrate  of 
silver  will  often  relieve  the  pain  of  either  hard  or  soft  corns.  Inflamed 
corns  require  elevation  of  the  foot  and  moist  antiseptic  dressings.  Gauze 
moistened  with  an  antiseptic  solution  and  covered  with  rubber  tissue, 
oiled  silk  or  waxed  paper  is  an  antiseptic  poultice  and  is  valuable.  Soft 
corns  are  benefited  by  dusting  tannic  acid  or  oxide  of  zinc  upon  them. 
These  modes  of  treatment  are  only  palliative.  Excisions  of  the  horny  cone- 
shaped  mass  by  careful  dissection  or  by  cutting  out  an  elliptical  portion 
of  tissue  down  to  the  superficial  fascia  is  the  radical  treatment.  If  abscess 
occurs  under  the  corn  prompt  incision  will  relieve  pain  and  probably 
effect  a  permanent  cure. 

It  must  be  remembered  that  the  peripheral  circulation  in  the  feet  of 
old  and  infirm  persons  is  not  vigorous  ;  hence,  slight  operative  interference 
may  be  followed  by  gangrene  in  such  patients. 


boil  or  furuncle.  155 

Boil  or  Furuncle. 

Definition. — A  boil  is  a  circumscribed,  painful,  and  reddish  elevation, 
due  to  a  localized  inflammation  of  the  skin  and  cellular  tissue  usually 
terminating  in  central  suppuration  and  sloughing. 

Pathology. — Furuncles  occur  singly  or  scattered  over  the  surface  in 
crops,  showing  a  predilection  for  the  back,  axillse,  perineum,  buttocks, 
legs,  and  face. 

They  are  at  times  associated  with  diabetes  and  other  diathetic  condi- 
tions. 

There  seem  to  be  two  classes  of  boils  :  Those  primarily  superficial,  due 
to  local  irritation  about  a  hair  follicle  or  sebaceous  gland,  as  when  the 
hands  are  exposed  to  irritating  fluids  in  dissecting  ;  and  those  which  begin 
deeply  on  account  of  a  localized  depressed  state  of  resistance  in  the  cellu- 
lar elements  of  the  skin  and  subcutaneous  tissue.  Boils  occur  among 
those  of  depraved  physical  condition  and  in  those  of  robust  and  vigorous 
health.  8ea  air  has  a  tendency  to  induce  their  appearance  in  manv 
people.  The  cause  of  furuncle-  is  a  mycotic  one.  The  cocci  in  many  in- 
stances enter  the  sebaceous  duct  or  hair  follicle  from  the  surface  of  the 
skin.  In  other  cases,  probably,  they  are  in  the  blood  and  become  local- 
ized at  a  point  where  the  tissues  have  least  resisting  power.  This  explains 
the  location  of  boils  and  their  occurrence  in  the  healthy. 

Symptoms. — The  sharp  stinging  pain  felt  upon  accidental  pressure  may 
first  call  attention  to  a  small,  red  jDimple,  which  gradually  enlarges,  be- 
comes hard  and  purplish,  and  is  surrounded  by  a  red  areola.  The  pain 
becomes  throbbing  and  constant,  about  the  fifth  day  a  yellowish  spot  at 
the  apex  of  the  elevation  pi'oclaims  the  occurrence  of  suppuration  and  in 
a  day  or  two  longer  a  cylindrical  greenish-yellow  core  or  slough  of  cellular 
tissue  is  discharged  by  the  suppurative  process,  leavintr  a  deep,  punched- 
out  looking  cavity.  This  is  gradually  filled  by  granulations,  the  adjacent 
exudation  of  lymph  is  absorbed  so  that  the  tissues  around  I'egain  their 
normal  softness,  and  cicatrization  is  finally  accomplished. 

The  course  of  a  moderate  size  boil,  that  is,  one  which  with  its  areola 
is  say  1^  inches  in  diameter,  is  run  in  eight  or  ten  days.  Pain  subsides 
as  soon  as  the  slough  or  core  is  discharged.  Smaller  boils  or  pimples  fre- 
quently appear  about  the  same  locality  some  days  after  the  disappearance 
of  the  primary  boil.  Lymphatic  glandular  involvement  is  common 
during  the  height  of  the  inflammation.  Occasionally  the  inflammation 
terminates  by  resolution,  and  as  no  discharge  takes  place  such  furuncles 
are  termed  blind  boils.     Severe  boils  usually  cause  some  fever. 

The  diagnosis  between  furuncle  and  its  congener,  carbuncle,  is  made 
by  the  single  point  of  suppuration,  the  circular  and  conical  shape,  the 
smaller  size,  the  tenderness  on  pressure,  which  does  not  exist  in  carbuncle, 
and  the  usual  association  with  other  boils. 

Treatment. — It  is  sometimes  possible  to  abort  furuncle  by  early  appli- 
cations of  tincture  of  iodine,  nitrate  of  silver,  blisters,  or  undiluted  carbolic 
acid,  or  by  puncture  with  a  red-hot  needle;  but  such  procedures  seem  at 
times  to  cause  the  subsequent  irruption  of  a  more  than  usually  virulent 
furuncle,  which  cannot  be  kept  in  check  by  such  measures.  Carbolic 
acid  has  been  injected  into  the  forming  boil  with  alleged  advantage. 

Pain  is  quieted  and  suppuration  probably  hastened  by  wet  antiseptic 
dressings  covered  with  rubber  tissue  or  oiled  silk  so  as  to  constitute  poul- 
tices, and  by  anodyne  plasters,  of  which  belladonna  plaster  is  one  of  the 


156  SURQERY    OF    SPECIAL    STRUCTURES. 

best ;  but  tbese  are  far  inferior  to  early  and  free  incision,  wbicb  relieves 
tension  and  paiii,  depletes  the  enp)rged  tissues  and  allows  rapid  extrusion 
of  the  slough.  It  is  the  effort  of  the  dead  cellular  tissue  to  escape  that, 
in  the  majority  of  instances,  causes  much  of  the  pain.  My  usual  course 
is  to  wait  only  until  the  boil  becomes  quite  painful,  when  I  at  once  make 
a  deep  incision  without  waiting  for  pus. 

Scraping  the  diseased  tissue  out  with  the  curette  while  the  patient  is 
etherized  may  hasten  cure.  This,  especially  if  followed  by  moist  anti- 
septic dressings  and  removal  of  the  slough  with  forceps,  speedily  relieves 
pain  and  shortens  the  duration  of  the  disease  several  days.  Dry  anti- 
septic dressings  should  be  used  after  the  slough  has  been  removed  or  dis- 
charged. 

The  treatment  of  the  condition  giving  rise  to  a  succession  of  boils 
(furunculosis)  is  difficult,  because  a  determination  of  the  underlying 
causes  is  often  impo.ssible.  Impoverished  blood  demands  iron,  (juinine, 
mineral  acids,  cod-liver  oil,  malt  and  alcoholic  beverages,  and  pure 
air.  Arsenic  (gr.  ^V  to  y'-),  hyposulphite  of  sodium  (.^ss  to  3j),  sulphide 
of  calcium  (gr.  ij  to  gr.  iv),  and  .solution  of  potassa  (n^xv  to  n\^xxx)  have 
some  reputation  as  antagonists  to  the  furunculous  diathesis,  and  one  or 
other  may  be  administered  three  or  four  times  daily.  Eliminative 
measures,  such  as  the  Turkish  bath,  should  be  employed  ;  and  any  gastric, 
intestinal,  or  genital  derangement  corrected.  Thorough  cleansing  of  the 
skin  with  soap,  aided,  2:)erhaps,  by  tur])entine,  ether,  and  non-poisonous 
antiseptics,  seems  most  philosophical.  The  occasional  a.ssociation  of  fur- 
unculous inflammations  with  syphilis,  septicteraia,  nephritis,  and  diabetes 
must  not  be  forgotten.  When  healing  does  not  progress  after  separation 
of  the  slough,  the  superficial  ulcer  left  requires  such  management  as  has 
been  previously  detailed  in  the  discussion  of  ulcers. 

Carbuncle. 

Definitiox. — Carbuncle  is  a  more  or  less  localized,  deeply  seated  sup- 
purative inflammation  of  the  skin  and  cellular  tissue,  attended  by  a  hard, 
very  painful,  flattened  swelling  and  asthenic  symptoms. 

Pathology. — This  section  does  not  discuss  the  disease  called  malignant 
pustule,  or  anthrax,  which  is  spoken  of  in  an  earlier  chapter.  Unfortu- 
nately the  term  anthrax  is  applied  to  both  diseases.  They  may  be  related. 
Malignant  pustule  is  certainly  due  to  the  anthrax  bacillus.  Carbuncle  is 
probably  due  to  a  pyogenic  organism.  There  is  a  great  clinical  similarity 
between  furuncle  and  the  more  severe  disease,  carbuncle;  while  there  is 
apparently  a  pathological  or  etiological  relationship  between  carbuncle 
and  malignant  pustule  and  erysipelas. 

.Symptoms. — Carbuncle  is  usually  single  and  is  most  frequent  in  elderly 
people  and  in  tho.se  of  impaired  health  ;  it  is  often  associated  with  dia- 
betes and  chronic  renal  disease.  A  chill  may  be  the  premonition  of  the 
carbuncle,  which  appears  as  a  painful  red  spot,  perhaps  surmounted 
by  a  vesicle.  The  posterior  part  of  the  trunk  and  neck  is  its  favorite 
locality.  A  firm,  flattened,  dusky  red  swelling,  evidently  involving  a 
considerable  depth  of  tissue  and  exceedingly  painful,  though  the  pain  is 
not  much  increased  by  pressure,  soon  shows  that  a  mere  furuncle  is  not  to 
be  expected.  The  brawny  inflammation  is  localized,  though  it  evinces 
some  tendency  to  spread,  which  is  quite  unlike  the  sharply  defined  fur- 
unculous affection.     This  suggests  a  possibility  that  carbuncle  may  be  due 


CARBUNCLE.  157 

to  the  Streptococcus  pyogenes  and  furuncle  to  one  of  the  other  pus-causing 
fungi.  The  feeling  ot  tension  and  the  throbbing  pain  are  very  marked, 
the  muscles  in  the  vicinity  become  stiff  from  pain,  and  glandular  swelling 
is  quite  prominent.  After  the  lapse  of  ten  days  or  two  weeks  the  skin 
softens,  first  perhaps  becoming  vesicular,  and  is  riddled  by  gangrenous 
openings  through  which  sloughing  cellular  tissue  and  ichorous  pus  is  dis- 
charged. Tough  fibrous  cores  or  sloughs  are  extruded  and  the  continuous 
destruction  of  skin  goes  on  until  there  is  left  a  deep  excavated  ulcer  with 
irregular  indurated  margins.  The  diameter  of  a  carbuncle  varies  from 
one  to  six  inches  and  it  may  extend  down  to  the  underlying  muscular 
tissue,  but  rarely  goes  beyond.  The  duration  of  the  disease  is  a  month  or 
six  weeks,  though  this  period  may  be  greatly  lengthened  by  indolent 
cicatrization  of  the  ulceration.  The  prognosis  is  exceedingly  unfavorable 
when  the  carbuncle  is  large  and  situated  upon  the  head  or  neck,  especially 
if  the  patient  is  old  or  infirm. 

The  constitutional  symptoms  are  asthenic,  and  are  of  course  more 
grave  if  the  sloughing  causes  profuse  hemorrhage. 

Treatment. — The  internal  treatment,  therefore,  comprises  supportive 
and  anodyne  measures,  for  even  preliminary  depletion  would  be  inadvis- 
able. Quinia  (gr.  x-xx  daily),  dried  sulphate  of  iron  (gr.  iij-vj  daily), 
and  milk  punch  (whiskey,  f5J-v  daily)  represent  the  character  of 
agents  to  be  employed  in  severe  cases. 

Ice  has  been  recommended  as  a  local  application  in  the  early  stage  to 
cause  the  disease  to  abort.  Blisters  are  sometimes  employed  with  a  sim- 
ilar object,  and  are  also  sometimes  applied  around  the  carbuncle  to  pre- 
vent extension  of  the  inflammation  by  causing  abundant  effusion  of 
serum.  Circular  compression  made  by  plasters  with  a  central  hole  over 
the  focus  of  inflammation  or  by  a  cupping  glass  has  advocates,  who  think 
that  the  progress  of  the  carbuncle  is  limited  or  its  severity  lessened  by 
this  device.  When  it  is  evident  that  arrest  cannot  be  accomplished,  moist 
antiseptic  dressings,  covered  with  rubber  cloth  to  prevent  evaporation, 
are  the  proper  applications  to  hasten  suppuration  and  the  discharge  of 
the  gangrenous  tissue.  Thorough  cleansing  with  sublimate  solutions 
(1  :  1000)  of  the  cavities  under  the  perforated  and  sieve-like  integument 
is  judicious.  Cicatrization  of  the  resulting  ulcer  is  accomplished  as  in 
ordinary  cases  of  ulceration  after  gangrene.  Stimulating  ointments  or 
lotions  and  skin-grafting  may  be  required.  The  cicatricial  contraction  is 
usually  less  than  would  seem  probable  from  the  extent  of  the  ulceration. 
This  is  due  to  the  fact  that  the  thickened  and  indurated  edges  give  the 
ulcer  a  factitious  depth. 

I  have  purposely  omitted  the  discussion  of  the  propriety  of  incising 
carbuncles  until  now,  because  high  authorities  differ  as  to  the  therapeutic 
value  of  incision.  Some  surgeons  seldom  incise  them  and  believe  that 
the  operation  as  a  rule  neither  hastens  cure  nor  lessens  suflering.  Others 
think  that  incision  is  beneficial  because  it  relieves  ihe  tension  and  conse- 
quent interstitial  strangulation,  diminishes  pain,  and  allows  early  escape 
of  pus  and  sloughs.  If  the  parts  are  relaxed  and  soft  no  incision  is  re- 
quired ;  but  tension  is  so  nearly  universal  that  I  am  impressed  with  the 
value  of  free  early  incision,  at  least  in  the  majority  of  cases.  The  creak- 
ing as  the  knife  divides  the  tissues  shows  the  great  induration.  My 
opinion  does  not  differ  from  that  expressed  under  the  treatment  of  boils. 
Subcutaneous  incision  is  inferior  to  a  direct  incision  which  may  or  may 
not  be  crucial.  Capillary  hemorrhage  may  be  pretty  free,  but  will  relieve 
engorgement,  and  is  not  likely  to  do  harm,  even  in  the  asthenic  condition 


158  SURGERY    OF    SPECIAL    STRUCTURES. 

present,  unless  a  vessel  of  considerable  size  is  wounded.  Pressure  with 
compresses  and  bandages  will  control  such  capillary  oozing  it"  it  is  suffi- 
cient to  require  treatment.  Applications  of  very  hot  water  have  a  styptic 
influence.  Early  curetting  of  the  diseased  region  so  as  to  remove  sloughs, 
j)us,  and  disintegrated  tissues  seems  to  me  rational.  It  must  be  done 
under  aniesthesia,  and  the  cavity  made  antiseptic.  Tlic  diseased  struc- 
tures may  be  destroyed  witliDUt  hemorrhage  by  the  application  of  caustic 
potassa,  which  cauterizes  and  causes  chemical  destruction  of  the  skin  and 
subcutaneous  tissue. 

Tliorough  cauterization  with  a  red-hot  iron  thrust  through  the  skin  and 
carried  under  the  skin  in  all  directions  may,  if  used  at  an  early  period, 
destroy  the  pyogenic  organism  and  prevent  spread  of  tlie  i)hlegmonous 
inflammation.     It  seems  to  me  a  valuable  suggestion. 

Lurus. 

Definition. — Lupus,  or  lupus  vulgaris,  is  a  chronic  cellular  inKltra- 
tion  of  the  skin,  exhibiting  itself  as  irregular,  nodular,  re(hli.>^h-brown 
patches  of  granulation  tis^^ue,  which  may  or  may  not  proceed  to  destruc- 
tive ulceration  but  which  usually  leave  disfiguring  cicatrices.  Lupus, 
as  previously  stated,  is  probably  a  form  of  cutaneous  tuberculosis,  due  to 
the  tubercle  bacillus. 

Pathology. — The  disease  has  an  important  surgical  bearing,  because 
there  is  a  liability  of  its  being  confounded  with  syphilitic  and  epithelio- 
matous  ulceration. 

The  superficial  form  of  lupus,  erythematous  lupus  as  it  is  called,  is  a 
very  different  affection  from  ulcerating  lupus.  It  is  a  skin  disease  located 
especially  in  the  sebaceous  glands  and  does  not  interest  the  surgeon. 

.Symptoms. — Lupus  begins  as  a  grouj)  of  small,  hardened,  reddish 
brown  points  in  the  skin  which  increase  until  they  become  papules  or 
tubercles.  The  patch  may  enlarge  or  several  small  patches  may  coalesce. 
There  is  no  pain.  Cure  may  occur  at  this  stage  by  absorption  of  the 
nodules,  leaving  an  atrophic  kind  of  scar;  or  destructive  ulceration  of 
the  affected  skin  may  take  place.  Such  ulceration  is  exceedingly  chronic 
and  is  characterized  by  accumulation  of  crusts,  slight  discharge,  slow  in- 
volvement and  destruction  of  underlying  cartilaginous  structures,  and 
contracting  cicatrices  which  cause  marked  deformity.  Ulcerating  lupus 
usually  attacks  the  face  in  the  neighborhood  of  the  mouth,  nose,  and 
ears,  but  may  appear  upon  other  parts  of  the  body,  especially  the  fingers. 
There  may  be  slight  pain  in  the  later  stages  of  the  disease. 

The  causation  of  lujnis  has  been  obscure,  but  is  now  believed  by  many 
to  be  due  to  the  tubercle  bacillus.  The  general  health  may  be  good.  It 
occurs  in  children  chiefly,  and  is  rare  in  this  country,  except  among  the 
foreign  element  of  our  population. 

Lupus  must  be  carefully  differentiated  from  syphilitic  ulcers  and  from 
epithelioma,  which  shows  a  predilection  to  attack  similar  regions  of  the 
face. 

Lupous  Ulceration.  Syphilitic  Ulceration. 

Comparatively  superficial.  Quite  deep,  often  excavated. 

.\rea  rather  small.  Area  may  be  quite  large. 

triceratiou  usually  limited  to  one  region.  Ulcers  often  disseminated  over  surface  of 

body. 
Increasesby  coalescing  of  adjacent  patches.  Ulcers  remain  separate. 

Border  illy  defined.  Border  sharply  defined. 


LUPUS, 


159 


Lupous  TJlceration. 

Discharge  slight  and  not  fetid. 
Scabs  thin  and  reddish-brown. 
Progress  slow,  takes  mouths  to  develop. 

Scars  hard,   yellowish,  and   have    great 

tendency  to  contract. 
Xo  other  lesions. 
Xot  improved  by  medicinal  treatment. 


Lupous  TJlceration. 

Usually  upon  face,,  may  attack  other  parts. 

Induration  not  very  marked  and  is  diffuse. 

Xo  pain. 

Ulceration  begins  at  several  points  of  the 

patch. 
Destruction    of    tissue    vsualli/  not  verj' 

great. 
'No  hard  and  everted  border  ever  present. 

Ulcer  usually  rather  superfic'al,  with  base 

of  small,  red  granulations. 
Slow  in  its  progress. 
Occurs  especially  in  children. 


Syphilitic  Ulceration. 

Discharge  abundant  and  foul. 

Scabs  thick,  otten  greenish. 

Progress  more  rapid,  a  large  ulcer  will  de- 
velop in  a  few  weeks. 

Sears  soft,  whitish,  have  little  contractile 
tendency. 

Lesions  of  bones,  glands,  etc. 

Cured  by  mercury  and  potassium  iodide 
in  full  doses. 

Epitheliomatous  Ulceration. 

Situated  usually  at  muco-eutaneous  junc- 
tions. 

Induration  well  marked  and  circum- 
scribed. 

Pain  may  be  quite  severe. 

Ulceration  begins  at  one  point  and  spreads. 

Destruction  and  loss  of  substance  great. 

Indurated  and  everted  border  a  charac- 
teristic. 

Ulcer  deep,  with  uneven  base  and  foul 
discharge. 

More  rapid  in  its  progress. 

Occurs  especially  in  adults  and  aged. 


It  will  be  seen  that  the  clinical  history  of  the  ulcerative  stages  of  these 
affections — lupus,  syphilis,  and  epithelioma— are  very  different.  I  am 
convinced  that  many  cases  described  as  lupus  have  really  been  epithe- 
lioma, for  the  great  destruction  of  tissue  and  abundant  discharge  and 
pain  attributed  to  lupus  are  antagonistic  to  its  ordinary  clinical  features. 
Rodent  ulcer,  which  is  a  form  of  epithelioma,  lupus  and  syphilis,  have 
been  confounded  by  many  writers,  who  have  thereby  confused  the  pro- 
fession. 

Treatment. — This  intractable  affection  requires  active  and  prolonged 
treatment.  Good,  nutritious  food,  general  hygienic  measures,  and  consti- 
tutional and  local  remedies  are  demanded. 

Cod-liver  oil  (f^ij  to  t'sss),  iodide  of  potassium  (gr.  v-x),  and  syrup 
of  iodide  of  iron  (io^s  to  fgj)  are  probably  the  most  valuable  internal 
remedies,  and  should  be  tested  before  severe  local  applications  are 
adopted.  Arsenic  is  a  constitutional  remedy  worthy  of  trial.  Caustics 
are  necessary  as  topical  remedies,  unless  absorption  of  the  infiltration 
occurs  in  the  early  stages  of  the  disease.  Absorption  may  possibly  be 
assisted  at  this  time  by  painting  with  tincture  of  iodine,  undiluted  or 
mixed  with  glycerin,  or  by  applying  tar  or  some  murcurial  ointment,  or 
using  iodoform  powder.  Later  it  becomes  necessary  to  use  caustics  to 
destroy  the  diseased  tissue.  Xitrate  of  silver  is  highly  recommended  by 
Hebra,  but  it  is  not  as  powerful  as  other  agents,  which,  however,  in  some 
instances  destroy  the  healthy  as  well  as  the  unhealthy  skin.  Potassa  and 
lime  are  painful  applications,  and  have  a  very  destructive  tendency; 
hence,  the  surrounding  parts  must  be  protected  by  pieces  of  plaster  or 
cloth,  and  some  weak  acid  should  be  at  hand  to  neutralize  the  alkali  if 
necessary.  Arsenious  acid  (gr.  xx-xxx  to  5j  of  ointment)  is  painful, 
but  acts  only  on  affected  structures.  Pyrogallic  acid  ointment  (3J  to 
5J)  is  painless,  and  acts  very  slightly  on  the  normal  tissue.  Chromic  acid, 
to  which  a  few  drops  of  water  have  been  added,  applied  with  a  brush,  is 
my  favorite  for  such  purposes.     Solution  of  ethylate  of  sodium  may  be 


160 


SUK(JKRY    OK    SPECIAL    STRUCTURES. 


used  {ind  is  efficacious  as  a  destroyer  of  abnormal  structures.  Scraping 
away  the  diseased  skin  with  a  sharp-edged  scoop,  or  curette,  and  applying 
caustics  subsequently,  such  as  zinc  chloride  or  one  of  those  mentioned 
above,  is  a  proper  and  often  an  efficient  method  of  treatment.  The 
thermo-cautery,  or  galvanic  cautery,  is  an  available  method  of  obtaining 
a  similar  object.  Excision  of  the  ulcer  may  sometimes  be  justifiable 
when  the  gap  can  be  closed  by  a  plastic  procedure.  Multiple  incisions 
are  said  to  be  beneficial  bv  arousing  traumatic  inflammation. 


Arabia X  Ei.kpiiantiasis. 

Definition. — Arabian  elephantiasis,  or  Barbadoes  leg,  is  a  local  dis- 
ease, characterized  by  chronic  hypertrophy  of  the  skin  and  underlying 
cellular  tissue,  giving  rise  to  discoh)ration,  thickening,  induration,  warty 
growths  and  deformity. 

It  is  essentially  different  from  Grecian  elephantiasis,  or  lepra,  the 
Biblical  leprosy,  which  is  probably  due  to  a  vegetable  parasite,  the  bacil- 
lus of  leprosy.     Leprosy  does  not  belong  to  the  domain  of  surgery. 


Fk;.  62. 


Aialiian  elephantiasis. 

Symptoms. — The  first  step  in  the  disease  is  a  local  inflaramation  of  an 
erysipelatous  kind,  accompanied  by  involvement  of  the  lymphatic  vessels 
and  glands.  This  attack  subsides,  leaving  the  part,  usually  a  leg  or  the 
genitals,  somewhat  enlarged  and  cedematous.  Recurrence  of  such  inflam- 
niatory  conditions  takes  place  at  intervals,  leaving  in  each  instance  more 
thickening  and  deformity.  In  the  course  of  a  yearor  two  the  hypertrophied 
skin  and  subcutaneous  tissue  cause  the  part  to  assume  enormous  propor- 
tions. The  thickened,  hardened  skin  hangs  in  irregular  folds,  and  the 
surface  often  becomes  eczematous.  From  the  accompanying  fissures  and 
ulcers  bloody  serum  exudes  and  causes  scabs  to  form.  The  surface  may 
be  smooth  and  eczematous,  or  very  rough,  from  the  development  of  papil- 
lary enlargements  or  warts.  The  enlai'ged  region  is  usually  darker  than 
natural  and  greatly  mis-shapen.  The  decomposing  secretions,  if  abund- 
ant, give  rise  to  fetor.  The  great  weight  is  a  source  of  inconvenience, 
and  pain  or  itching  may  at  times  add  to  the  patient's  discomfort.    During 


BURNS.  161 

the  active  inflammatory  periods  fever  is  present,  and  the  local  symptoms 
are  more  severe. 

Arabian  elephantiasis  is  not  common  in  the  United  States,  but  is  fre- 
quently seen  in  the  West  Indies,  South  America,  and  other  tropical  coun- 
tries. A  condition  resembling,  if  not  identical  with  it,  is  not  infrequently 
seen  associated  with  chronic  leg  ulcer.  The  cause  is  obscure,  but  is  prob- 
ably connected  with  the  lymphatic  system.  The  disease  is  attributed  by 
some  investigators  to  occlusion  of  the  lymphatic  vessels  by  an  animal 
parasite,  the  filaria.  It  is  found  among  the  poor,  especially  in  adults,  and 
is  neither  hereditary  nor  contagious.  It  is  always  chronic  in  its  progress, 
and  does  not  tend  to  a  fatal  issue.  One  of  the  legs,  the  scrotum,  penis,  or 
vulva  is  the  usual  situation  of  the  disease. 

Pathologically  it  consists  of  an  hypertrophy  of  the  skin  and  areolar 
tissue,  with  enlarged  bloodvessels  and  dilated  lymphatics.  In  very  pro- 
tracted cases  muscular  atrophy  and  degeneration,  and  thickening  of  the 
bones  take  place. 

Treatment. — It  should  be  treated  in  the  acute  inflammatory  stages  by 
rest  in  the  horizontal  posture,  and  by  cold  water  and  anodyne  applica- 
tions. When  these  symptoms  have  abated  inunction  with  mercurial  oint- 
ment, painting  with  tincture  of  iodine,  and  the  application  of  the  elastic 
bandage  are  the  best  methods  of  inducing  absorption  and  diminution  of 
bulk.  Continuous  elevation  of  the  limb  should  always  form  an  impor- 
tant factor  of  the  treatment.  The  rapid  decrease  in  size  under  elevation 
and  frequent  readjustment  of  the  elastic  bandage  is  often  a  matter  of 
astonishment,  but  the  hypertrophy  is  liable  to  return  when  the  patient 
regains  the  erect  position.  The  eczematous  complication  is  often  bene- 
fited by  a  paste  of  salicylic  acid  (^ij),  carbolic  acid  (^ij),  zinc  oxide  (^ss), 
mucilage  (3xx),  and  glycerin  (^xx). 

Ligation  of  the  main  arterial  trunk  has  been  followed  by  amelioration, 
and  Dr.  T.  G.  Morton,  of  Philadelphia,  has  reported  very  favorable  results 
in  a  case  where  he  excised  an  inch  and  a  quarter  of  the  sciatic  nerve  five 
years  after  ligation  of  the  femoral  artery  had  been  performed  with  partial 
success.     Amputation  may,  at  times,  be  justifiable. 

Burns. 

Definition. — Burns  are  injuries  produced  by  the  application  to  the 
surface  of  heat  sufiicient  to  cause  inflammation  or  destroy  the  vitality  of 
the  tissues.     Scalds  are  burns  due  to  contact  with  hot  fluids. 

Pathology. — Sunburn  is  a  dermatitis  or  inflammation  of  the  skin 
resembling  that  caused  by  heat,  but  due  to  exposure  to  the  sun's  rays. 
Such  inflammation  is  prevented  by  protecting  the  skin  with  dark  veils  or 
clothing,  and,  when  caused,  is  to  be  treated  as  an  ordinary  burn  by  cool- 
ing and  anodyne  applications.  Injuries  due  to  the  chemical  action  of 
strong  acids  and  alkalies  are  improperly  called  burns,  though  the  eflfects 
are  similar  to  those  caused  by  heat. 

Injuries  from  chemicals  should  be  treated  locally  at  first  by  weak  alka- 
line or  acid  solutions  to  neutralize  respectively  the  acid  or  alkali  doing 
the  mischief.  The  subsequent  treatment  is  identical  with  that  of  burns. 
Lightning  and  contact  with  electric  light  wires  sometimes  cause  burns, 
in  addition  to  the  nervous  phenomena  due  to  the  electric  current.  The 
burns  are  to  be  treated  as  other  burns. 

The  local  eflTects  of  contact  with  heat  necessarily  depend  upon  the  tem- 

11 


162  SURGERY    OF    SPECIAL    STRUCTURES. 

perature  and  the  time  of  exposure.  There  are  practically  only  three 
classes  of  burns:  1.  Erythematous  burns,  or  tho.se  .s)  superficial  in  their 
influence  that  nothing  further  than  hypera^mia  and  slight  serous  effusion 
into  the  skin  occur.  2.  Vesicating  burns,  which  do  a  greater  degree  of 
damage,  and  are  followed  by  vesicles  resulting  from  an  ert'usion  of  serum 
between  the  derma  and  ejMdermis.  3.  Necrotic  burns,  which  are  followed 
by  eschars,  becau.se  the  upper  portion  of  the  derma,  or,  perhaps,  the  whole 
thickness  of  the  skin  or  the  muscles,  fascite,  and  bones,  are  devitalized. 

Sy.mpto.m.s. — In  erythematous  burns  the  skin  is  red,  painful,  and 
swollen  ;  but  these  inflammatory  symptoms  subside  in  a  few  hours  or 
days,  and  no  cicatri.x  is  left,  even  when  desfpiamation  takes  place. 

Vesicating  burns  promptly  show  vesicles  or  blebs  fllled  with  clear  or 
blood-stained  serum,  and  are  the  seat  of  active  inflammation  causing  severe 
pain.  The  serum  escapes  by  rupture  of  the  vesicle,  or  is  absorbed,  and  a 
new  epidermis  is  formed  in  the  course  of  a  week.  If  the  old  cuticle  is 
early  cast  ofl"  or  removed  by  friction,  so  that  the  cutis  is  exposed  to  irri- 
tation and  to  pus  infection  from  pyogenic  germs,  in  the  air  or  on  the 
clothing,  great  pain  and  superficial  su])puration  result. 

Xo  cicatrix  follows  vesicating  burns,  though  a  discolored  stain,  similar 
to  that  often  seen  after  blistering  with  cantharides,  may  remain  for  a  con- 
siderable period. 

Necrotic  burns  destroy  the  vitality  of  the  tissues ;  therefore  the  eschars, 
when  separated,  leave  ulcerated  surfaces  to  heal  by  granulation.  The 
pain  of  such  burns  is  intense,  if  shock  does  not  prevent  its  being  felt.  The 
dirty  brown  color  of  such  burns  is  characteristic,  but  it  is  ijupossible  to 
tell  how  deep  the  destruction  has  been  until  the  sloughs  separate.  If  the 
parts  are  kept  aseptic  there  will  be  no  suppuration  under  the  eschars, 
which  will  drop  off'  when  the  parts  beneath  are  healed.  Cicatricial  con- 
traction and  deformity  are  usually  great.  The  cicatrices  may  assume  a  very 
rough  and  irregular  aj>pearance  from  abnormal  development  of  fibrous 
tissue.     Keloid  and  malignant  degenerations  at  times  attack  such  scars. 

The  constitutional  effects  of  burns  vary  with  the  amount  of  surface  in- 
volved and  the  degree  of  burning.  An  erythematous  burn  of  a  large 
surface  will  cau.se  more  dangerous  symptoms  than  a  deeper  burn  of 
limited  area.  When  burns  are  severe  enough  to  cause  constitutional 
manifestations,  these  symptoms  are  exhibited  in  three  stages:  1,  that  of 
shock;  2,  that  of  inflammatory  fever;  3,  that  of  exhaustion. 

The  stage  of  shock  is  accompanied  by  feeble,  frequent  pulse,  great  de- 
pression of  the  nervous  system,  lowered  temperature,  chills,  nausea,  rest- 
lessness, and  perhaps  delirium.  Pain  is  not  very  prominent  if  shock  is 
great.  Greater  shock  attends  burns  of  the  trunk  than  of  the  limbs. 
Congestion  of  the  brain,  of  the  thoracic  and  abdominal  organs  occurs, 
and  the  patient  often  dies  in  twelve  or  twenty-four  hours  without  showing 
any  rea*'tion  from  the  collapsed  state.  The  degree  of  shock  shown  by 
children  and  the  aged  is  greater  than  in  the  nii(ldle  period  of  life. 

The  stage  of  inflammatory  fever,  which  lasts  from  the  second  to  about 
the  fourteenth  day,  is  characterized  by  increased  bodily  temperature,  dis- 
ordered secretions,  great  thirst,  and  often  by  inflammation  of  the  internal 
organs,  such  as  cerebral  meningitis,  bronchitis,  pleuro-pneumonia,  and 
enteritis.  It  is  due  largely,  if  not  entirely,  to  infection  by  putrefactive 
and  pyogenic  germs  of  the  burned  surfaces.  Ulceration  of  the  duodenum, 
sometimes  proceeding  to  perforation,  is  a  remarkable  lesion  occurring  at 
times  during  this  stage.  It  is  to  be  suspected  if  hypogastric  pain,  vomit- 
ing of  blood,  abdominal  tenderness,  and  bloody  stools  are  observed.     Its 


BURXS.  163 

occurrence  has  been  attributed  to  the  unusual  vicarious  action  thrown 
upon  the  duodenal  glands,  and  also  to  a  possible  embolic  plugging  of  the 
vessels  of  the  intestine.     Neither  of  these  theories  has  been  proved. 

Duodenal  ulcer,  if  it  occurs,  is  developed,  as  a  rule,  about  the  seventh 
or  tenth  day  of  the  inflammatory  stage.  In  this  stage  albuminuria  varv- 
ing  with  the  temperature,  and  a  small  vascular  eruption  thickly  scattered 
over  the  trunk,  have  been  noticed.     Erysipelas  may  occur. 

The  stage  of  exhaustion  is  due  to  the  depression  caused  by  the  inflam- 
matory irritation,  and  by  the  profuse  suppuration  often  accompanving  the 
detachment  of  the  eschars  and  the  cicatrization  of  the  resulting  ulcers. 
The  suppuration  is  due  to  pyogenic  infection,  which  is  difiicult  to  pi-e- 
vent  when  large  areas  are  injured.  Infection  usually  occurs  before 
the  surgeon  reaches  the  burned  individual.  There  is  great  debilitv  but 
no  pain  unless  the  ulcers  are  subjected  to  pressure  or  rudely  handled  in 
reapplying  dressings.  Amyloid  visceral  changes  may  possibly  result  from 
prolonged  suppuration. 

Few  cases  of  severe  burn,  and  superficial  burns  must  be  considered 
severe  if  one-third  of  the  surface  is  injured,  survive  until  the  suppurative 
stage  begins.  The  majority  die  of  shock  within  the  first  thirty-six  hours. 
Many  others  die  during  the  inflammatory  stage  from  lesions  of  the  in- 
ternal organs,  tetanus,  etc.  Inflammatory  cedema  of  the  glottis  from 
inhalation  of  steam  may  be  a  cause  of  death  ;  but  flame  itself  is  not  in- 
haled, as  is  supposed  by  the  laity.  In  most  instances  where  incinerated 
bodies  are  found  in  burned  buildings  asphyxia  has  occurred  from  the 
gaseous  products  of  combustion  before  the  tissues  have  been  subjected  to 
the  action  of  fire.  Spontaneous  combustion  of  the  human  body  is  im- 
possible. 

Treatment. — The  constitutional  treatment  of  burns  should  be  di- 
rected to  the  relief  of  shock  and  pain,  the  prevention  of  secondary 
visceral  inflammations,  and  the  support  of  the  general  powers  of  the 
system ;  while  topical  remedies  should  be  employed  to  relieve  pain, 
moderate  local  inflammation,  prevent  infection  with  pus  and  other  germs, 
hasten  cicatrization,  and  prevent  contractile  deformity. 

Reaction  from  shock  should  be  sought  for  by  the  application  of  heat 
and  the  administration  of  stimulants  and  concentrated  food  in  small 
quantities.  The  hot  bath  may  be  available  to  raise  temperature  and  re- 
lieve pain.  In  fact,  all  the  measures  spoken  of  in  the  cha])ter  where 
Shock  after  AVounds  is  discussed  are  to  be  employed.  Pain  is  to  be 
relieved  in  severe  cases  by  an  immedicie  hypodermic  injection  of  a  quarter 
or  half  grain  of  morphia,  or  by  the  inhalation  of  an  anesthetic.  In  the 
later  stages  of  burns  laxatives,  diuretics,  revulsives,  and  other  anti- 
phlogistic measures  may  be  demanded  to  prevent  internal  inflammation 
and  to  substitute  the  derivative  action  of  the  skin.  The  stage  of  exhaus- 
tion preeminently  requires  tonics;  and  on  this  account  actively  depressing 
remedies  are  to  be  avoided  in  the  inflammatory  stage. 

The  local  treatment  varies  with  the  degree  of  burn.  Erythematous 
burns,  if  limited  in  extent,  are  relieved  of  pain  by  solution  of  sodium 
bicarbonate,  cold  water,  lead  water  and  laudanum,  and  in  fact  by  almost 
any  dressing  that  excludes  air  and  eonstringes  the  dilated  capillaries. 
Menthol  or  Japanese  peppermint  might,  I  think,  from  its  great  refrigerant 
action,  be  exceedingly  soothing.  The  application  of  cold  to  large 
erythematous  burns  is  ill-advised  because  of  the  tendency  to  depress  the 
surface  temperature  and  congest  the  internal  organs.  A  household 
remedy  for  small  burns  of  this  degree  is  to  hold  the  part  near  a  hot  fire 


164  SURGERY    OF    SPECIAL    STRUCTURES. 

and  thus  apply  dry  heat.     Zinc  ointment  spread  on  cloth,  aiid  wheat  Hour 
dusted  over  tlie  burned  surface  are  recommended  higlily. 

The  proper  treatment  for  vesicating  burns  is  to  puncture  the  blebs  care- 
fully and  allow  the  serum  to  escape,  so  as  to  prevent  the  epidermis  irom 
being  rudely  rubbed  off.  This  epidermis  makes  the  be.st  possible  i)rotec- 
tion  from  irritation  and  septic  infection.  Antiseptic  gauze,  or  cotton,  or 
some  form  of  dry  sterilized  dressing  should  then  be  applied.  Salicylic 
acid  cotton  does  well.  Sublimate  cotton  would  be  apt  to  poison  the 
patient  if  used  for  extensive  burns.  The  dressing  should  not  be  changed 
oftcner  than  once  in  two  or  three  days,  because  detachment  of  loosened 
cuticle  and  exposure  to  air  increase  pain  and  the  liability  to  germ  infec- 
tion. Antiseptic  powders  form  with  the  exuded  fluids  a  coating  which 
serves  as  a  good  protection  from  atmospheric  influences,  and  should  not 
be  removed  until  detached  spontaneously.  Iodoform  powder  is  liable  to 
give  rise  to  toxic  symptoms  when  used  in  large  quantity.  Boric  and 
salicylic  acids  are  harmless,  or  practically  so.  Sluch  harm  is  often  done 
by  tearing  off  the  epidermis  when  removing  underclothing.  It  is  better, 
perhaps,  in  such  cases,  to  leave  the  soiled  shirt  or  drawers  upon  the  body 
and  saturate  it  with  carbolizcd  ca.stor-oil  (1  :  15)  applied  upon  the  outside. 
Three  days  later,  if  the  ])atient  live  so  long,  less  harm  will  be  occasioned 
by  cutting  and  removing  the  garments  In  this  method  suppuration  is  to 
be  expected  since  infection  from  the  skin  and  clothing  is  almost  certain. 

Necrotic  burns  require  the  same  line  of  treatment  as  vesicating  burns, 
with  which  indeed  they  are  usually  associated.  After  separation  of  the 
sloughs  the  ulcers  are  to  be  treated  as  previously  described  under  Ulcera- 
tion. jNIetallic  astringents  are  often  exceedingly  valuable  to  keep  down 
redundant  granulations  and  hasten  repair  of  the  breach  of  continuity. 
Skin-grafting,  in  its  numerous  forms,  is  often  required,  and  lessens  con- 
traction of  the  cicatrix.  Deep  burns  of  extremities  may  be  so  destructive 
to  tissue  or  so  threaten  life  by  reason  of  spreading  gangrene,  hemorrhage, 
or  violent  inflammation  that  amputation  gives  the  best  prospect  of  re- 
covery. 

AVhen  possible  burned  surfaces  should  at  once  be  rendered  aseptic  by 
thorough  cleansing  and  disinfection  Avith  antiseptic  solutions.  To  do  this 
etherization  and  scrubbing  the  burned  surface  with  soap  and  a  brush  may 
be  justifiable  if  the  patient's  condition  does  not  contra-indicate.  Deaths 
occurring  after  the  period  of  reaction  are  largely  due  to  sepsis. 

The  greatest  ingenuity  has  to  be  called  into  ])]ay  in  the  endeavor  to 
prevent  cicatricial  contraction,  which  is  especially  marked  when  a  deep 
burn  has  injured  the  surface  of  a  joint.  The  irresistible  power  of  the  scar 
contractility  everts  the  margins  of  mucous  orifices,  as  in  ectropium, 
narrows  the  outlets  of  normal  canals,  flexes  or  extends  joints  and  renders 
them  immovable,  drags  features  out  of  position,  causing  horrid  deformity, 
and  binds  neighboring  members  together  into  one  mass.  During  cicatri- 
zation this  contraction  should  be  prevented  as  much  as  possible  by  keep- 
ing joints  extended  by  splints  or  by  weights  applied  .with  adhesive  plaster 
or  by  elastic  bands.  Adjacent  surfaces  should  be  kept  separated  by 
similar  measures  or  by  interposed  dressings  or  metallic  plates.  It  must 
be  remembered  that  two  apposed  granulating  surfaces  will  readily  become 
connected  by  union  by  second  intention.  In  this  way  several  fingers  may 
be  united  throughout  their  entire  length,  if  not  enveloped  in  separate 
dressings.  Much  can  be  accomplished  by  careful  and  judicious  treatment 
to  prevent  marked  cicatricial  deformity;  but  some  disfigurement  will 
often  occur  despite  the  best-directed  efforts. 


FROSTBITE    AND    CHILBLAIN.  165 

Recent  cicatrices  may  be  stretched  to  a  certain  extent,  but  old  ones 
usually  require  operative  treatment. 

Correction  of  deformity  may  at  times  be  accomplished  by  multiple  in- 
cision of  the  scar  tissue,  or  by  subcutaneous  incisions  and  unfolding  of 
inodular  ridges.  Plastic  operations  are  often  requisite  and  gain  the 
desired  end  by  transferring  the  tension  to  some  neighboring  region  where 
the  cutaneous  structures  are  sufficiently  distensible  to  allow  traction  with- 
out causing  distortion.  The  various  means  of  transferring  tissue  by 
sliding,  twisting,  and  transplanting  with  and  without  pedicles  will  be 
found  under  Plastic  Surgery. 

Frostbite  and  Chilblain. 

Definition. — Frostbite  is  the  injury  produced  by  the  application  to 
the  surface  of  cold  sufficient  to  cause  inflammation  or  to  destroy  the 
vitality  of  the  tissues. 

Chilblain,  or  pernio,  consists  in  a  local  paralysis  and  dilatation  of  the 
capillaries  of  the  skin  caused  by  previous  frostbite,  giving  rise  to  a  bluish- 
red  swelling  accompanied  by  great  itching  and  tenderness,  and  which 
may  terminate  in  vesication  and  ulceration. 

Symptoms. — When  a  man  is  exposed  to  extreme  cold  the  circulation 
and  respiration  become  feeble,  the  limbs  stiff  and  numb,  the  senses  are 
overcome  by  drowsiness,  and  he  sinks  into  a  comatose  state.  If  he  is 
not  rescued  from  this  condition  of  apparent  death,  the  fatal  issue  occurs 
from  congestion  of  the  brain  and  other  organs  induced  by  the  contraction 
of  the  vessels  of  the  surface.  The  proper  method  of  restoration  is  the 
very  gradual  application  of  warmth  by  means  of  friction  with  snow  or 
cold  water,  followed  by  removal  to  a  very  slightly  warmed  apartment, 
and  the  careful  use  of  stimulants  internally  and  warm  embrocations  ex- 
ternally. Friction  with  clothes  should  also  be  made  in  the  direction  of 
the  venous  current.  Artificial  respiration  and  other  measures  should  be 
persisted  in  for  many  hours. 

It  is,  however,  the  local  and  not  the  general  effects  of  cold  that  we  are 
now  studying.  Frostbites  resemble  burns,  except  that  their  course  is 
slow,  and  like  burns  are  of  three  degrees  of  severity:  1,  erythematous; 
2,  vesicular  ;  3,  necrotic. 

Erythematous  frostbite  follows  exposure  to  a  moderate  degree  of  cold 
and  is  due  to  the  capillary  congestion  and  slight  inflammatory  serous 
effusion  that  succeed  the  primary  contraction  of  the  vessels.  The  skin 
during  the  application  of  the  low  temperature  becomes  white  from  defi- 
cient circulation,  wrinkled  and  numb ;  but  as  soon  as  return  to  warmth 
occurs  a  bluish-redness,  swelling,  and  tingling  pain  or  itching  arise.  The 
equilibrium  of  circulation  is  restored  gradually  and  no  further  patholog- 
ical changes  occur. 

When  the  cold  is.greater  or  more  prolonged  the  parts  become  white, 
entirely  insensible  and  shrunken,  and  reaction  is  accompanied  by  inflam- 
mation, leading  to  vesication.  The  vesicles  in  vesicating  frostbite  are 
filled  usually  with  blood-stained  serum,  and  there  is  danger  of  gangrene 
occurring  from  the  violence  of  the  inflammatory  process. 

Extreme  cold  devitalizes  the  tissues  at  once  and  they  have  a  mottled 
appearance  from  coagulation  of  blood  in  the  superficial  vessels.  It  is 
said  that  the  part  may  be  brittle  and  easily  broken,  like  glass.  The 
necrosed  structures  are  finally  separated  in  the  same  manner  as  sloughs 


166  SURGERY    OF    SPECIAL    STRUCTURES. 

produced  by  heat  or  chemical  agents.  In  these  cases  of  necrotic  frost- 
bite, as  well  as  in  vesicating  frostbite  leading  to  gangrene  because  of 
active  inflammation,  it  is  impossible  to  tell  how  much  of  the  tissues  is 
capable  of  having  phy^^iological  function  restored.  Amputation,  there- 
fore, must  not  be  attempted  in  the  primary  condition  of  the  injury. 

The  extremities  and  the  peripheral  points,  such  as  the  ears,  no.se,  and 
chin,  are  most  frequently  frozen,  because  normal  circulation  is  le.ss  active 
in  these  localities.  For  a  similar  rea.son  persons  with  weak  hearts,  and 
those  enfeebled  by  di.sease,  dissipation,  or  old  age  are  nio.><t  liable  to  suffer 
from  exposure  to  low  temperatures. 

Parts  of  the  body  subjected  to  constriction  from  tight  clothing,  as 
gloves,  or  shoes,  or  kept  in  contact  with  metal  are  especially  apt  to  be 
frozen.  Cold  combined  with  moisture  or  wind  is  more  dangerous  than 
cold  and  dry  weather  without  wind. 

Chilblains  are  local  dilatations  of  the  cutaneous  capillaries,  due  to 
slight  frostbites,  usually  to  freezing  that  has  been  repeated.  The  con- 
gestion which  occurs  in  these  paralytic  vessels  is  accompanied  by  oedema, 
bluish-red  swelling,  severe  itching  and  burning,  and  occasionally  by  the 
formation  of  vesicles  and  intractable  ulcers.  They  are  most  frequent  in 
women  and  young  persons,  and  those  of  feeble  cutaneous  circulation,  and 
give  more  trouble  when  the  weather  changes  from  cold  to  warm  than 
when  it  is  continuously  cold.  When  the  limbs  become  warm  after  going 
to  bed,  or  when  the  patient  has  been  indulging  in  stimulating  food  or 
beverages,  the  itching  becomes  almost  intolerable. 

Tkkatment. — The  treatment  of  all  degrees  of  frostbite  should  begin 
by  preventing  sudden  return  to  normal  temperature,  because  sudden 
access  of  blood  to  the  injured  capillaries  will  cause  pain  and  a  high  degree 
of  inflammation.  Hence  the  parts  should  never  be  subjected  to  heat  or 
put  in  warm  water.  The  circulation  and  sensibility  are  to  be  restored 
gradually  by  friction  with  articles  only  a  little  warmer  than  the  frozen 
parts.  Snow,  ice  water,  and  wet  cloths  are  usually  employed  for  this 
purpose.  Afterward  slightly  stimulating  applications,  such  as  alcohol, 
may  be  used  to  complete  the  reaction.  Elevation  of  the  limb  and  friction 
toward  the  trunk  may  be  valuable  accessories,  because  the  venous  return 
is  thus  assisted  and  congestion  in  the  semi-paralyzed  capillaries  rendered 
less  intense. 

The  erythematous,  vesicular,  and  necrotic  inflammations  that  occur 
after  reaction  has  been  established  are  to  be  treated  very  much  as  burns 
of  similar  degrees  Anodyne  and  cooling  lotions  or  ointments,  evacua- 
tion of  the  serum  in  the  vesicles,  protection  of  the  skin  from  atmospheric 
contact,  so  as  to  avoid  infection,  and  moist  antiseptic  dressings,  perhaps, 
to  separate  the  sloughs,  are  all  indicated  in  the  various  degrees  of  injury. 
The  resulting  ulcers  are  managed  as  such,  without  regard  to  their  causa- 
tion. Amputation  is  frequently  required  after  severe  frostbite,  but  should 
not  be  done  until  the  line  of  demarcation  has  been  definitely  formed. 
Parts  that  are  insensitive  when  a  needle  is  thrust  into  them  at  the  time  of 
freezing,  will  often  have  the  circulation  restored,  much  to  the  surprise  of 
the  surgeon. 

The  treatment  of  chilblains  is  very  unsatisfactory.  Tincture  of  iodine  ; 
carbolic  acid  (I  :  10)  ;  carbolized  ointment  of  petroleum  ;  nitrate  of  silver 
(1:40);  menthol;  tinctui-e  of  cantharides  ;  tincture  of  aconite  root ;  mus- 
tard foot-baths;  nitric  acid  (1  : -SO)  ;  ammonia;  turpentine  or  camphor 
liniment;  chloroform;  metallic  astringents  and  chloral,  as  lotions  or  un- 
guents, and  similar  applications,  are  to  be   tried.      Tincture  of  iodine 


INGROWING    TOE-NAIL.  167 

(n\^xx),  ether  (fgij),  collodion  (fsj),  may  be  applied  with  a  brush. 
Perhaps  hypodermic  injections  of  fluid  extract  of  ergot  (tt\^x)  or  of  ergo- 
tine  (gr.  iij)  near  the  seat  of  pain  would  be  beneficial.  All  pressure  from 
shoes  or  gloves  aggravates  the  pain,  and  should,  therefore,  be  avoided. 
The  ulcers  that  occur  demand  treatment  calculated  to  cause  healing  and 
to  alleviate  the  itching  pain,  but  care  must  be  observed  not  to  employ 
remedies  that  will  induce  serious  inflammation. 


Onychia  or  Onychitis. 

Definition. — Onychia,  or  onychitis,  is  an  inflammation  and  ulcera- 
tion of  the  matrix  of  a  nail  of  the  fingers  or  toes,  by  which  the  nail  is 
discolored  and  usually  loosened,  and  finally  cast  off.  Onychia  must  be 
distinguished  from  paronchia,  or  felon,  which  is  an  entirely  different 
affection. 

Symptoms. — The  condition  may  or  may  not  arise  from  injury,  and  is 
most  frequently  observed  in  children  as  a  simple  inflammation  and  suppu- 
ration about  the  root  of  the  nail.     The  new  nail  that  supplies  the  place 
of  the  diseased  one  is  commonly  irregularly  developed.  At  times  onychitis 
assumes  a  much  more  serious  and  intractable  form.     The  ulceration  ex- 
hibits no  tendency  to  heal,  the  foul  discharge  and  fungous  granulations 
show  the  finger  or  toe  to  be  in  an  unhealthy  in- 
flammatory condition,  the  end  of  the  member  be-  Fig.  63. 
comes  bulbous  from  morbid  deposits,  and  caries  or            , 
necrosis   of    the   phalanx   occurs.      This   form   of          /       glf.    %|| 
onychia,  which  is  chronic  in  its  course,  has  been 
called  malignant,  and  frequently  is  syphilitic  in  its 
origin. 

Treatment. — The  treatment  in  simple  cases  con-       ,      ,,;.     ,        ,,^j 
sists  of  antiseptic  lotions  and  dressings,  and  anodyne       j      Jj     j'-   ;^'-i^ 
solutions  or  ointments.     The  cases  depending  upon 
constitutional  states  require  internal  remedies,  such      f -^^,^1    i 
as  iodide  of  potassium,  mercury,  and  tonics.     Lo-     1 1  j|||        ;-;  ;,  ;;c. 
cally,  cauterization  with  solid  nitrate  of  silver  or      \^/ 
nitrate  of  lead,  or  the  application  of  iodoform,  of  '  M;      ~     ;. 

nitrate  of  mercury  ointment,  or  arsenious  acid  oint- 
ment Cgr.  ij  to  5j)  is  proper.     Scraping  away  the  ^-— __- 
fungous   granulations    and    irregularly   developed               Onychitis. 
nail  tissue  often  assists  in  effecting  cure.     Entire 

ablation  of  the  nail,  and  even   amputation  of  the  finger  may  become 
necessary. 

Ingrowing  Toe-nail. 

Definition. — Ingrowing  toe-nail  is  a  vicious  position  of  the  lateral 
border  of  the  nail  in  relation  to  soft  parts  of  the  toe,  by  which  the  former 
is  buried  in,  or  overlapped  by,  the  latter. 

Symptoms. — The  malposition  of  the  nail  may  be  due  to  abnormal  cur- 
vature of  the  same,  to  tight  shoes  pressing  the  soft  tissues  over  its  border, 
or  to  a  collection  of  hardened  cuticle  under  the  nail,  causing  it  to  assume 
an  unnatural  relation  to  the  adjacent  structures.  The  affection  is  usually 
seen  at  the  outer  edge  of  the  great  toe,  and  becomes  in  time  very  painful, 
because  the  constant  pressure  gives  rise  to  inflammation  and  ulceration 


168 


SURGERY    OF    SPECIAL    STRUCTURES. 


before  the  cotton  is  inserted. 


Fig.  64. 


with  foul  discharge.     The  corner  of  the  nail   may   even  perforate   the 
substance  of  the  toe. 

Treatment. — Palliative  treatment  consists  in  allowing  the  nail  to  grow 
forward,  and,  after  scraping  away  the  thickened  cuticle  beneath,  to  keep 
the  square  corner  elevated  by  a  small  piece  of  cotton  carefully  pushed 
under  it.  By  a  similar  piece  of  cotton  or  lint  the  border  of  the  toe 
should  be  kept  pressed  away  from  the  dorsal  aspect  of  the  nail  margin. 
The  shoes  worn  must  be  wide  in  the  sole,  belong,  and  have  toe.s  high 
enough  to  make  no  pressure  on  the  top  of  the  nail.  The  ulceration,  if 
it  exists,   should    be   treated  with    nitrate  of  silver  or   nitrate  of  lead 

Salicylic  acid  (ojss),  extract  of  cannabis 
indica  (gr.  x),  collodion  (.^j)  make  a  good 
application.  In  inveterate  cases  the  soft 
parts  may  be  pared  away  obliquely  by  an 
incision  beginning  as  lar  back  as  the  root 
of  the  nail.  This  fully  exposes  the  ulcer, 
and  by  bevelling  off  the  side  of  the  toe 
prevents  the  nail  irritating  the  tissues; 
hence  cicatrization  and  cure  usually  follow. 
At  times,  however,  it  is  better  to  remove 
the  oftending  portion  of  nail.  This  is  done 
by  carrying  an  incision  through  the  length 
of  the  nail,  about  a  quarter  of  an  inch  from 
the  edge,  beginning  far  enough  up  the  toe 
to  extend  beyond  the  root  of  nail.  A 
transverse  cut  is  then  made  from  the  upper 
end  of  this  incision,  and  a  second  longi- 
tudinal one  carried  through  the  inflamed 
skin  in  such  a  manner  as  to  liberate  the  buried  border  of  the  nail.  The 
lateral  portion  of  the  nail  is  then  pulled  away.  The  unhealthy  and 
swollen  soft  parts  near  the  nail  are  generally  also  trimmed  off". 

The  raw  surface  left  by  the  avulsion  is  soon  healed  by  granulation 
under  the  ordinary  dressings  for  exposed  and  non-approximated  wounds. 
This  is  a  better  operation  than  removing  the  entire  nail ;  for,  even  if  both 
margins  have  to  be  cut  out,  the  centre  of  the  toe  still  retains  its  covering 
of  nail  tissue. 

In  many  cases  the  surgeon  can  make  his  second  longitudinal  incision 
run  under  the  skin  obliquely  and  thus  free  the  incurvated  margin  of  nail 
without  leaving  so  large  a  surface  for  granulation.  This  is  a  sort  of  a 
subcutaneous  excision  of  the  nail  border. 

The  operation  is  practically  bloodless  if  a  piece  of  tape  is  tightly  tied 
around  the  root  of  the  toe  before  the  incisions  are  made.  Cocaine  solu- 
tion may  be  injected  into  the  tissues  so  as  to  produce  local  ana^sth&sia. 
Its  incarceration  by  the  tape  ligature  increases  the  degree  of  ansesthesia. 


Operation  for  ingrowing  toe- 
nail. Tape  around  root  of  toe  to 
prevent  bleeding,  and  incarcerate 
cocaine  solution  injected  hypo- 
dermically. 


CHAPTEK     XIY. 

DISEASES   AND   INJUEIES   OF   MUSCLES,    TENDONS   AND 

BUES^E. 

WOUNDS   AND    RUPTURES    OF   MUSCLES   AND    TENDONS. 

Incised  and  lacerated  wounds  of  muscles  and  tendons,  if  they  involve 
the  entire  thickness  of  the  structure,  are  followed  by  retraction  of  the  cut 
ends  and  loss  of  motion.  The  treatment  consists  in  relaxing  the  muscular 
belly  by  flexion  or  extension  of  the  joints,  and  applying  sutures  to  hold 
the  divided  muscular  or  tendinous  structures  together. 

In  suturing  tendons  it  is  well  to  pull  down  the  upper  end  strongly  in 
order  to  stretch  and  paralyze  the  muscles  and  then  to  overlap  the  ends 
and  stitch  them  together  in  that  position  by  longitudinal  sutures.  If  the 
tendon  is  wide  the  suture  illustrated  in  Fig.  50  is  a  good  one.  After 
suturing  the  limb  should  be  kept  for  several  weeks  in  the  position  which 
relaxes  the  muscles.  This  can  be  done  by  bandages  or  the  plaster-of- 
Paris  dressing.  If  the  torn  belly  of  the  muscle  protrudes  through  a 
small  cutaneous  wound  it  must  be  pushed  back,  even  if  the  opening  in 
the  skin  requii-es  to  be  enlarged  to  accomplish  this  object.  Excision  of 
the  muscular  protrusion  is  usually  improper.  If  the  upper  portion  of 
the  tendon  is  so  retracted  in  its  sheath  that  it  cannot  be  pulled  down  by 
narrow-blade  forceps,  an  incision  upward  must  be  made  so  that  it  can  be 
found.  A  tendon  should  b6  attached  to  a  neighboring  tendon  or  muscle 
when  it  is  impossible  to  find  the  two  ends  of  the  severed  coi"d.  This  will 
prevent  entire  paralysis  of  the  finger  or  limb  to  which  the  tendon  is  in- 
serted. Tenosuture  and  myosuture  are  often  neglected  in  wounds  accom- 
panied by  division  of  the  tendons  and  muscles.  In  such  improperly 
treated  cases  the  loss  of  motion  may  be  so  detrimental  that  it  is  judicious 
to  cut  through  the  cicatrized  parts,  even  after  several  years  have  elapsed, 
and  pare  the  ends  of  the  separated  tendon  or  muscles  and  suture  them 
properly.  As  a  rule,  tendons  divided  subcutaneously,  as  in  tenotomy,  re- 
unite quickly  and  satisfactorily  as  to  function ;  but  when  their  surround- 
ings have  'been  freely  divided,  as  in  open  wounds,  good  union  does  not 
follow  unless  sutures  have  been  applied  to  the  cut  tendons.  This  is  due 
to  the  great  retraction  of  the  muscular  end  which  occurs  in  such  wounds. 

Subcutaneous  rupture  of  a  few  muscular  fibres  is  not  uncommon  in 
severe  strains  thrown  suddenly  upon  the  muscles,  and  usually  is  accom- 
panied by  sudden,  sharp,  localized  pain  and,  perhaps,  ecchymosis.  Eest, 
the  elastic  bandage,  and  massage,  supplemented,  pei-haps,  by  friction  with 
some  sorbefacient  liniment  is  the  treatment  requisite.  The  cure  is  usually 
somewhat  slow. 

Complete  rupture  of  the  belly  of  a  muscle  or  of  its  tendon,  either  from 
the  bony  insertion  or  at  the  musculo-tendinous  junction,  is  rather  unusual 
though  not  rare.  Violence,  or  a  sudden  powerful  muscular  contraction, 
as  in  tetanus  or  in  the  effort  to  recover  equilibrium  when  about  to  fall,  is 
the  cause  of  such  lesions.  When  muscles  have  undergone  fatty  or  other 
degenerative  changes,  rupture  is  possible  from  very  slight  strain ;  but 


170  MUSCLES,   TENDOXS    AND    BURS^:. 

these  tears  are  unattended  by  pain,  as  a  rule,  and  do  not  concern  us 
surgically.  The  tendon  of  the  long  head  of  the  biceps,  that  of  the  calf 
muscle.s,  and  that  of  the  four-headed  extensor  of  the  leg  are  the  tendons 
most  frequently  torn. 

The  s-yniptoins  of  rupture  of  a  muscle  or  tendon  are  the  occurrence 
during  action  of  sharp  pain,  accompanied  possibly  by  an  audible  snap 
and  associated  with  almost  complete  loss  of  motion,  a  groove  or  depres- 
sion in  the  surface  and,  in  muscular  rupture,  ecchymosis.  The  degree  of 
separation  of  the  ends  depends  upon  the  amount  of  laceration  of  the  sur- 
rounding tissues  and  may  be  as  much  as  an  inch.  If  the  tendon  is  wide 
some  power  of  motion  may  remain  because  the  margin  is  intact;  as  in  a 
case  seen  by  me  a  few  years  ago,  where  there  was  slight  extension  possible 
after  rupture  of  the  tendon  inserted  into  the  patella.  Some  fibres  from 
the  external  vastus  muscle  had  evidently  escaped  rupture. 

Rupture  of  muscles  and  tendons  should  be  treated  by  laying  open  the 
overlying  tissues  and  suturing  the  torn  structures  with  chromicized  cat- 
gut. The  limb  should  then  be  placed  in  the  posture  which  tends  to  keep 
the  extremities  of  the  torn  organ  near  together,  and  should  be  so  retained 
by  bandages,  splints,  plaster-of-Paris  dressings  or  by  an  apparatus  of 
straps  adapted  to  this  requirement. 

Local  weakness  remains  a  long  time  after  union  of  ruptured  muscles 
and  tendons ;  and  the  repair  that  occurs  is  usually  of  analogous  tissue, 
which,  in  the  case  of  tendons,  however,  finally  assumes  the  characteristics 
of  the  original  tissue. 

Dislocation  of  Muscles  and  Tendons. 

Dislocation  of  a  tendon  occasionally  occurs  when  a  sudden  strain  or 
twist  is  l)rought  to  bear  upon  it  at  a  point  when  its  direction  is  changed 
by  passing  around  a  bony  prominence.  The  long  head  of  the  biceps  of 
the  arm,  the  long  and  short  peroneal  and  the  posterior  tibial  tendons  are 
more  frequently  displaced  than  any  others.  Dislocation  of  the  patella  is 
usually  practically  a  dislocated  tendon  containing  a  sesamoid  bone. 

Reduction  is  easily  accomplished  by  relaxation  of  the  muscle  and  pres- 
sure upon  the  displaced  tendon,  but  as  the  sheath  is  torn  in  such  luxa- 
tions, it  is  difficult  to  keep  the  tendon  in  place  after  i-eduction.' 

Pressure  with  pads  and  the  elastic  bandage  will  often  be  effectual,  but 
sudden  strain  is  apt  to  reproduce  the  luxation  and  pain. 

Tenotomy  may  be  resorted  to  in  cases  of  repeated  luxation,  as  has  been 
done  by  Mr.  Bryant.  It  is  possible  that  some  cases  might  be  benefited 
by  open  incision,  followed  by  suturing  neighboring  structures,  so  as  to 
prevent  subsequent  displacement. 

It  is  probable  that  muscles  themselves  sometimes  become  displaced 
from  the  grooves  in  which  they  lie.  Such  cases  would  probably  be  bene- 
fited by  manipulation,  followed  by  bandaging. 

Inflammation  of  Tendons. 

Symptoms. — Tenosynovitis,  or  inflammation  of  the  tendons  and  their 
fibrous  and  synovial  coverings,  may  be  acute  or  chronic.     Thecitis,  the 

1  Comparatively  little  has  been  written  on  these  injuries,  but  the  reader  may  find  inter- 
esting facts  in  New  York  Med.  .Journal,  Mav,  1878,  and  British  Med.  Journal,  July  13, 
1878. 


INFLAMMATION    OF    TENDONS.  171 

term  often  used,  properly  refers  to  iuflammation  of  the  theca  or  sheath 
alone,  but  as  both  structures  are  involved  in  the  majority  of  instances, 
the  word  tenosynovitis  is  a  preferable  designation  of  the  condition. 

Acute  tenosynovitis  is  produced  by  punctured  and  other  wounds,  or 
may  arise  without  any  traumatism,  and  is  usually  found  affecting  the 
flexor  tendons  of  the  fingers  or  toes.  The  pain  and  other  inflammatory 
symptoms,  both  local  and  constitutional  are  very  severe,  and  may  ter- 
minate in  diff"use  suppuration,  sloughing,  necrosis  of  the  phalanges,  and 
septicaemia.  The  rapid  spread  of  the  inflammation  to  the  hand  and  arm 
by  burrowing  of  pus  along  the  tendinous  sheaths  and  by  gangrenous  cel- 
lulitis, suggests  in  many  of  these  cases  a  resemblance  to  erysipelas.  The 
severe  forms  of  paronychia,  often  called  whitlow  or  felon,  are  usually 
instances  of  inflammation  of  tendons,  beginning  at  the  end  of  the  finger. 
Sometimes  the  term  whitlow  is  used  to  signify  a  mere  suppurative  inflam- 
mation of  the  cellular  tissue  of  the  pulp  of  the  finger- tip,  a  simple  abscess 
in  fact ;  but  the  destructive  paronychia,  which  is  followed  by  gangrene 
and  necrosis,  involves  the  tendinous  structures  and  periosteum. 

Treatment. — Acute  inflammation  of  tendons  demands  purgatives, 
sedatives,  and  morphia  internally,  and  hot  applications  and  elevation 
locally,  which  must,  however,  be  followed  very  early  by  free  incision  to 
prevent  burrowing  of  pus  along  the  sheaths.  A  free,  longitudinal  in- 
cision should  be  practised  in  the  middle  line  of  the  tendun,  going  through 
the  structures  down  to  the  bone.  This  should  be  done  as  soon  as  it  is 
seen  that  resolution  of  the  inflammation  will  not  occur,  and  without  wait- 
ing for  the  formation  of  pus.  The  limb  should  be  kej)t  elevated  after- 
ward and  enclosed  in  a  moist  antiseptic  dressing.  In  whitlow  supposed 
to  involve  only  the  structures  about  the  tendon,  it  has  been  recommended 
to  incise  on  both  sides  of  the  middle  line  rather  than  in  the  centre  of  the 
finger,  in  order  to  avoid  opening  the  sheath  and  thereby  allow  the  sup- 
purative and  sloughing  action  to  involve  the  tendon.  My  own  opinion  is 
that  it  is  not  probable  that  the  incision  into  the  sheath  adds  materially  to 
the  risk  of  the  involvement  of  the  tendinous  structures,  if  the  incision  is 
sufficiently  free  to  allow  all  discharges  external  exit. 

Necrosis,  subsequent  to  acute  tenosynovitis,  may  necessitate  resection  of 
a  joint  or  amputation  of  a  portion  of  the  finger  or  limb. 

Stifihess  or  deformity  of  joints  is  a  frequent  sequel  of  well-treated  cases 
of  acute  tenosynovitis. 

Constitutional  diseases,  such  as  rheumatism,  gout,  and  syphilis,  are 
liable  to  cause  inflammation  of  the  fibrous  tissue  of  tendons  and  aponeuro- 
ses, but  this  is  not  of  the  phlegmonous  kind,  and  demands  therapeutic 
management,  depending  on  the  cause.  Alkalies,  salicylic  acid,  colchicum, 
iodide  of  potassium,  and  mercury  are  to  be  administered  as  indicated. 

There  is  a  peculiar  form  of  chronic  inflammation  of  the  sheath  of  ten- 
dons accompanied  by  a  characteristic  creaking  or  crackling  felt,  and  some- 
times heard,  on  motion  that  must  be  mentioned.  This  crepitating  thecitis 
usually  occurs  in  the  forearm,  and  seems  to  be  due  to  roughening  of  the 
sheaths  by  lymph,  which  causes  scraping  when  the  tendons  slip  in  the 
investing  coverings.  The  inflammation  apparently  results  from  long- 
continued  and  violent  muscular  action,  or  from  gout  or  rheumatism,  and 
is  associated  with  a  moderate  amount  of  pain  and  occasionally  with  tender- 
ness and  swelling.  The  term  "  thecitis  "  is  properly  applied  to  this  con- 
dition. 

The  crepitation  felt  when  the  wrist  is  flrmly  grasped  by  the  other  hand 
is  characteristic.     Its  superficial  character  and  occurrence  during  volun- 


172  MMSCLES,    TENDONS    AND    BURS^. 

tary  motion  make  it  very  different  from  the  crepitus  of  fracture.  It 
should  be  treated  by  rest,  the  elastic  baudage,  blisters,  and  friction  with 
stimulatins:  liniments. 


Deformities  from  Muscular  Paralysis,  Contraction,  and 
Rkjidity. — Myotomy  and  Tenotomy. 

Pathology. — Any  disturbance  of  the  normal  equilibrium  of  the  mus- 
cular forces  gives  rise  to  deformity,  hence  it  is  evident  that  such  deformity 
may  be  due  to  increased  action  of  one  set  of  muscles  or  to  iini)aired  power 
of  the  opposing  group.  There  are  four  methods  by  which  muscular  dis- 
tortions occur:  1.  Inflammation  of  muscular  tissue  (myo.sitis),  which  is 
often  due  to  gout,  rheumatism,  and  syphilis,  may  lead  to  rigidity  and  con-, 
traction  of  muscles.  2.  Long-continued  abnormal  position  or  disuse  of 
muscles,  such  as  result  from  an  unreduced  dislocation  of  a  bone,  and  from 
inflammation  or  anchylosis  of  a  joint,  may  be,  and  usually  is,  followed  by 
spastic  contraction,  o.  Lesions  in  the  nerve  centres  may  give  rise  to  par- 
tial or  complete  paralysis  of  a  group  of  muscles,  and  thus  allow  the  antago- 
nistic muscles  to  exert  unrestrained  force;  or,  on  the  other  hand,  the 
central  nervous  disease  may  cause  such  a  tonic  contraction  of  certain 
muscles  that  their  opponents  are  unable  to  resist  the  displacing  tendency. 
In  either  event  deformity  ensues.  4.  Irritation  of  the  peripheral  nerves 
may,  by  a  reflex  influence,  cause  contraction  or  paresis  of  neighboring  or 
distant  muscles.  Such  instances  are  seen  in  connection  with  diseased 
teeth  and  gums,  and  with  intestinal  and  uterine  irritation. 

Treatment. — The  management  of  deformities  arising  from  abnormal 
muscular  action  should  difter  with  the  cause  of  the  disturbance  of  muscular 
equilibrium.  If  it  is  impaired  function  that  causes  the  distortion  the 
weakened  muscles  should  be  strengthened  by  systematic  exercise,  elec- 
tricity, massage,  and  hypodermic  injections  of  strychnia,  and  by  remedies 
directed  to  the  promotion  of  the  nervous  supply.  Brain  or  spinal  cord 
disease  should  be  sought  for  and,  if  possible,  removed. 

After  eflfbrts  to  strengthen  the  paretic]muscles  have  proved  unavailing, 
their  action  may  be  supplemented  by  elastic  tension  or  some  form  of 
mechanical  support.  Mechanical  appliances  tend  to  do  harm  if  they 
entirely  substitute  the  action  of  the  weak  muscles,  because  they  remove 
the  stimulus  to  exertion.  Hence,  the  early  treatment  should  be  such  as 
will  encourage  the  development  of  power.  If  this  is  found  impracticable, 
mechanical  agencies  to  aid,  but  not  to  substitute,  are  a  proper  resort. 

Muscular  contraction  from  syphilis,  gout,  and  rheumatism  can  often  be 
relieved  by  iodide  of  potassium,  mercury,  colchicum,  morphia  or  atropia 
hypodermically,  alkalies,  massage,  Turkish  baths,  and  similar  measures. 
Spastic  contraction  from  cerebral  or  spinal  disease  is  to  be  treated  by  the 
proper  remedies  for  the  lesion  there  existing  ;  and  that  due  to  abnormal 
position  or  disuse,  by  restoring  the  function  to  the  osseous  or  other  struc- 
tures primarily  involved.  Passive  motion  will  often  be  all  that  is  re- 
quired to  give  suppleness  to  the  stiffened  muscles  around  an  impaired 
joint. 

Repeated  stretching  by  manipulation,  or  continuous  stretching  by 
weights,  elastic  extension,  or  mechanical  apparatus  adjusted  with  screws 
will  often  overcome  muscular  rigidity  and  deformity.  The  removal  of  the 
source  of  peripheral  irritation  has  often  been  promptly  followed  by  relief 
of  the   muscular  contraction   or  paresis.     Tonic  spasm  of  the  ma-sseter 


MUSCULAR    PARALYSIS,    CONTRACTION,    ETC. 


173 


muscle  Jias  been  quickly  cured  by  extracting  a  wisdom  tooth  occupying 
an  abnormal  position  in  the  alveolus.  When  the  nervous  irritation  is 
central  and  cannot  be  removed,  stretching  or  excision  of  a  portion  of  the 
nerve-trunk  supplying  the  contracted  muscle  may  be  useful  in  curing 
deformity  and  relieving  the  pain  which  often  accompanies  the  condition 
of  muscular  spasm.  It  is  not  impossible  that  cases  may  occur  in  which 
it  would  be  good  surgery  to  trephine  the  skull  and  remove  the  cortical 
brain  centre. 

When  ordinary  measures  have  been  unsuccessful  in  curing  deformity 
due  to  muscular  contraction  the  patient  should  be  subjected  to  division  of 
the  displacing  muscle.  This  operation  is  done  subcutaneously  and  con- 
sists in  cutting  through  the  belly  or  tendon  of  the  muscle  with  a  narrow, 
short-blade  knife  called  a  tenotome. 

Division  of  the  muscular  fibres  is  myotomy,  division  of  the  tendon, 
tenotomy ;  but  the  latter  term  is  sometimes  used  to  include  division  of 
muscles  and  fascias  as  well  as  of  tendons.  It  is  usually  better  to  cut  the 
tendon  than  the  muscle,  if  a  choice  is  possible,  since  the  muscular  gap  is 
repaired  by  fibrous  tisssue  and  not  by  muscle,  while  the  two  ends  of  the 
divided  tendon  are  united  by  tissue  almost,  if  not  quite,  identical  with 
tendinous  structure.  The  operation  practically  inserts  a  piece  of  new 
tendon  in  the  gap  and  thus  lengthens  the  muscle.  If  the  tendon  is  so 
short  as  to  be  inaccessible,  the  muscular  belly  may  be  divided. 

Tenotomy  should  not  usually  be  performed  if  the  deformity  depends 
upon  palsy  of  the  opposing  muscles,  nor  if  the  deformity  can  be  over- 
come by  moderate  mechanical  power  applied  by  apparatus  or  by  manual 
force. 

In  ophthalmic  surgery  tenotomy  is  sometimes  performed  when  double 
vision  is  due  to  a  strong  muscle  overbalancing  a  paretic  one. 

Fig.  65. 


Tenotome  with  round  end  and  aseptic  metal  handle. 


The  tenotome  should  have  a  short  cutting  edge  and  a  rounded  end 
somewhat  keen  in  order  to  divide  the  skin,  but  it  should  not  be  pointed. 
There  is  then  no  need  of  a  preparatory  incision  of  the  skin  with  another 
instrument  and  no  danger  of  the  point  injuring  vessels.  The  shank  of 
the  knife  should  be  strong,  but  slender  to  permit  turning  in  the  small 
wound,  and  the  handle  so  marked  that  the  position  of  the  cutting  edge 
imbedded  in  the  tissues  can  be  determined.  It  is  usually  preferable  to 
divide  the  tendon  by  inserting  the  tenotome  under  it  and  cutting  toward 
the  surface.     This,  however,  is  not  a  matter  of  much  moment. 

The  operation  is  seldom  followed  by  any  untoward  results.  After  the 
edge  of  the  tendon  or  muscle  has  been  determined  by  the  thumb-nail  of 
the  left  hand  and  while  the  parts  are  kept  stretched  and  tense  hj  an 
assistant,  the  operator  slips  the  tenotome  flatwise  through  the  skin  and 


174  MUSCLES,    TENDONS    AND    BURS^. 

under  the  tendon.  The  edge  of  the  knife  is  then  turned  against  the  rigid 
cord,  which  is  completely  divided  hy  a  sawing  motion  and  separates, 
perhaps,  with  a  snap,  so  as  to  leave  a  distinct  gap  under  tiie  skin.  If  this 
springing  apart  of  the  ends  is  not  very  evident  some  of  the  fibres  of  the 
tendon  have  escaped  division,  or  other  tendons,  or  some  bands  of  ccm- 
tracted  fascia  re(|uire  section.  These  must  be  searched  for  and  cut.  Then 
the  knife  is  turned  flatwise  and  withdrawn.  As  it  is  removed  the  surgeon 
presses  the  blood  out  after  it  in  order  that  no  air  may  enter  the  puncture. 
A  gauze  dressing  is  finally  placed  over  the  wound,  which  unites  by  first 
intention.  The  skin  and  instrument  must  be  a.septic  in  this  as  in  all 
surgery. 

After  tenotomy  it  is  usual  to  bring  the  deformed  member  into  good 
position  at  once  by  manipulation  and  retain  it  so  by  appropriate  appa- 
ratus. Some  authorities  think  it  well  to  wait  a  few  days  before  attempt- 
ing restitution  of  position,  but  this  does  not  seem  to  me  judicious.  The 
operation  is  not  done  to  stretch  the  parts,  but  to  ])ut  the  foot  or  limb  in 
proper  position  and  substitute  a  long  tendon  for  a  short  one,  and  the 
forcible  manipulation,  if  done  at  once,  is  painless,  because  the  patient  has 
not  recovered  from  the  anaesthetic. 

Tenotomy  may  at  times  be  demanded  for  the  relief  of  other  conditions 
than  spastic  contractions,  club  foot,  and  similar  deformities. 

In  oblique  fractures  with  great  displacement  tenotomy  may  be  re<[uired 
to  allow  proper  adjustment  of  the  fragments.  The  tendon  of  Achilles  is 
the  one  that  is  most  likely  to  be  cut  for  this  reason.  Recurring  painful 
spasm  of  muscles  about  inflamed  joints  may  sometimes  justify  such  a  pro- 
cedure. 

In  performing  tenotomy  the  vicinity  of  arteries  and  nerves  must  be 
recollected.  The  posterior  tibial  vessels  and  nerves  near  the  inner  border 
of  the  tendon  of  Achilles  and  the  peroneal  nerve  just  inside  of  the  outer 
hamstring  tendon  are  to  be  carefully  avoided.  It  is  fortunate  that  when 
tendons  need  to  be  cut  they  generally  stand  out  in  relief  because  of  their 
tenseness  and  rigidity. 

This  prominence  can  be  made  more  marked  by  an  assistant  extending 
or  flexing  the  joints.  Hence,  the  risk  of  dividing  other  structures  which 
are  not  tense,  is  reduced  to  a  minimum.  Small  veins  and  arteries  may  be 
divided  with  impunity,  because  the  wound  is  subcutaneous  and  pressure 
is  readily  applied. 

Care  must  always  be  taken  not  to  puncture  inadvertently  with  the  point 
of  the  tenotome  the  skin  on  the  opposite  side  of  the  limb.  The  finger  of 
the  surgeon  should  be  kept  upon  that  surface  to  avert  such  an  accident. 

Contraction  of  the  Palmar  Fascia  and  Its  Digital 
Prolongations. 

Definition. — This  seems  to  be  the  proper  place  to  consider  the  peculiar 
flexion  of  the  fingers  which  has  been  called  Dupuytreu's  contraction.  It 
is  a  contraction  of  the  palmar  fascia  and  its  digital  prolongations,  not  in- 
volving the  flexor  tendons,  which  is  found  especially  in  male  patients 
beyond  the  middle  period  of  life,  and  which  seems  to  be  associated  with 
and  caused  by  the  gouty  diathesis. 

Symptoms. — The  little,  the  ring,  and  the  middle  fingers  are  most  fre- 
quently involved,  though  the  other  fingers  and  even  the  thumb  may  be 
similarly  affected.     The  patient  notices  that  during  several  years  a  finger 


CONTRACTION    OF     PALMAR    FASCIA. 


175 


Fig 


3 


becomes  more  and  more  flexed  upon  the  palm,  until  even  forcible  exten- 
sion is  impossible  and  the  first  and  second  phalanges  are  so  bent  that  the 
last  phalanx  and  nail  are,  perhaps,  pressed  against  the  surface  of  the  jDalm. 
This  gradually  increasing  deformity 
and  disability  is  painless.  The  neigh- 
boring fingers  and  even  one  or  two 
fingers  of  the  other  hand  may  subse- 
quently present  the  same  distortion. 

Examination  of  the  palm  shows  one 
or  more  tense  cords  or  ridges  under  the 
skin  extending  to  the  sides  or  middle 
of  the  affected  fingers.  The  disease 
shows  a  markedly  hereditary  tendency, 
and  according  to  recent  investigations 
is  evidently  of  a  gouty  etiology.  Trau- 
matism has  been  thought  to  be  a  cause, 
but  the  history  of  the  cases,  the  heredi- 
tary character  of  the  affection,  its  ocur- 
rence  in  both  hands  with  almost  equal 
frequency,  and  its  comparative  infre- 
quency  in  females,  who  are  known  to 
be  more  free  from  gout  than  males, 
make  injury  a  rather  improbable  etio- 
logical factor. 

The  diagnosis  of  this  affection  fi-inn 
stifiness  of  the  fingers  due  to  arthritis 
or  to  inflammation  about  the  tendons 
is  readily  made.  Chronic  changes  in 
the  skin  and  joints,  preventing  perfect 
extension  of  all  the  fingers,  is  seen  in 
the  hardened  hand  of  the  sailor  and 
laborer.  These  conditions  are  very  dif- 
ferent in  appearance  from  Dupuytren's 
contraction  of  the  palmar  fascia.  The 
rigid  cord  or  cords  extending  from  the 
middle  of  the  palm  forward  upon  the 
sides  or  middle  of  the  fingers  and  pro- 
ducing flexion  of  the  first  and  second 
phalanges  especially,  the  elevation  of 
the  skin  over  these  bands,  and  the  in- 
volvement   in    the    gi'eat    majority  of 

cases  of  one  or  more  of  the  fingers  of  the  ulnar  side  of  the  hand,  point 
unmistakably  to  contraction  being  in  the  palmar  fascia. 

A  similar  contraction  of  the  plantar  fascia  may  occur,  but  it  is  very 
much  more  unusual  than  the  disease  in  the  hand. 

Treatment. — In  the  early  stages  of  the  deformity  friction,  passive 
motion,  and  retention  on  a  straight  splint  for  a  long  time  may  prevent  the 
increasing  distortion,  and,  perhaps,  restore  the  function  of  the  finger.  As 
the  cases  usually  present  themselves  operation  and  prolonged  treatment 
by  splints  and  passive  motion  are  necessary.  The  contracted  fascia  and 
its  digital  prolongation  should  be  freely  divided  by  a  small  tenotome  in- 
troduced between  the  skin  and  fascia  at  various  points.  The  finger  should 
be  at  once  fully  extended  and  kept  in  that  position  by  a  splint,  which 
should  be  worn  constantlv  for  several  weeks.     Even  after  the  splint  is 


Dissection  of  finger  contraction,  affect- 
ing middle  and  ring  fingers.  Con- 
tracted band  of  palmar  fascia  stretches 
across  like  string  of  a  bow.  Flexor  ten- 
dons, b  lying  deeply  along  the  con- 
cavity of  the  curve,  close  to  the  bones, 
are  bound  down  along  the  first  pha- 
langes of  the  fingers  by  the  dense, 
tubular  sheath  through  which  they 
pass.  Digital  prolongations  extend  to 
articulation  between  first  and  second 
phalanges  in  each  fingnr.     (Adams.) 


176 


MUSCLES,    TENDONS    AND    BURS.E, 


dispensed  with  duriii<r  the  day  it  should  be  applied  and  worn  at  night.  It 
has  been  reconiraendod  to  dissect  up  a  trianifular  flap  of  skin  in  order  to 
cut  away  the  tense  fascia  piecemeal,  but  the  subcutaneous  method  of 
Adams  described  is  usually  eflicient. 


Fic.  C7. 


Fio.  RS. 


Contraction  of  palmar  fascia  before 
operation.  (Case  from  Polyclinic  Hos- 
pital.) 


Contraction  of  palmar  fascia  after  mul- 
tiple subcutaneous  incision. 


If  the  open  method  is  adopted  the  apex  of  the  flap  should  be  in  the 
palm  over  the  prominent  band  of  contracted  fascia,  while  the  base  should 
be  made  far  enough  forward  on  the  linger  to  give  access  to  the  median 
and  lateral  digital  bands,  which  may  extend  as  far  as  the  second  phalanx. 
After  these  fibrous  ridges  have  all  been  clip[)ed  away  the  cutaneous  flap 
is  sutured  in  its  former  position. 


Thecal  Cyst  or  Ganglion. 

Definition. — The  term  ganglion  is  frequently,  though  ill-advisedly, 
applied  to  cystic  tumors  connected  with  the  sheaths  of  tendons.  This 
name  should  be  discarded,  because  it  has,  in  another  sense,  become  so 
intimately  associated  with  the  anatomy  of  the  nervous  system. 

Symptoms. — This  form  of  cystoma,  or  cystic  tumor,  is  seldom  found 
except  in  connection  with  the  tendons  about  the  wrist  and  ankle.  In 
symptoms  and  treatment  the  disease  much  resembles  chronic  inflammation 
of  the  normally  existing  burste,  which  will  be  described  hereafter.  The 
cause  of  these  cysts  is  unknown,  though  they  may  be  due  to  strain  or 
some  other  form  of  traumatism. 

The  simple  cyst,  which  is  most  frequently  seen  on  the  radial  side  of  the 
back  of  the  wrist,  occurs  as  a  globular  swelling  situated  over  the  carpus, 
smooth,  elastic,  quite  tense,  somewhat  movable  and  unaccompanied  by 


THECAL    CYST    OR    GANGLION 


177 


discoloration  of  the  surface.     An  elongated  cyst  extending  along  the 
sheath  of  an  extensor  tendon,  such  as  is  shown  in  Fig.  69,  is  rare. 


Fio.  69. 


Cvstie  tumor  of  tendon  sheath. 


There  is  no  pain  unless  nerve  pressure  exists,  but  the  tumor  causes  a 
feeling  of  weakness  at  the  wrist.-  Authorities  differ  as  to  whether  such 
cysts  are  developed  upon  the  sheath  of  the  tendon,  or  are  localized  dilata- 
tions of  the  sheath  cavity  containing  the  synovial  fluid  of  the  sheath  more 
or  less  altered  in  character.  If  formed  in  the  latter  way,  the  orifice  of 
communication  probably  becomes  occluded  during  the  progress  of  the 
tumor,  for,  as  a  rule,  the  cyst  does  not  seem  to  connect  with  the  interior 
of  the  sheath. 

The  compound  ganglion,  as  the  other  variety  is  called,  is  more  fre- 
quently found  connected  with  the  flexor  tendons,  and  is  a  general  dilata- 
tion of  the  sheath  cavity,  which  may  involve  several  tendons.  This  tumor, 
though  a  cystoma,  and  though  called  a  compound  ganglion,  has  not,  as  a 
rule,  the  multilocular  character  of  compound  cysts.  The  term  compound 
is  applied  to  it  rather  because  of  its  being  a  more  complicated  and  moz-e 
troublesome  affection  than  the  simple  ganglion  just  described.  It  is  an 
irregular,  fluctuating  tumor,  often  giving  on  manipulation  a  creaking 
sound  and  a  peculiar  crepitant  sensation  to  the  finger  of  the  examiner. 
It  contains  synovial  fluid,  which  may  be  dark  or  bloody,  and  in  which  are 
frequently  found  floating  many  small  bodies,  resembling  rice-grains.  It 
is  these  seed-like  bodies  which  give  rise  to  the  crepitation.  They  are  little 
masses  of  lymph,  probably  derived  from  the  cyst  wall,  which  may  present 
a  roughened  internal  surface.  The  tumor  is  not  painful,  but  when  located 
in  the  palm  of  the  hand,  its  most  common  situation,  causes  flexion  and 
impaired  motion  of  the  finger.  The  tumor  is  not  tensely  filled,  and  it  is 
easy  to  press  the  fluid  from  the  palmar  portion  of  the  tumor  upward, 
under  the  annular  ligament,  until  the  distention  is  exhibited  at  the  wrist. 

Both  forms  of  cystic  tumor  of  the  tendons  may  be  found  in  the  foot  and 
other  localities.  In  this  connection  must  be  mentioned  the  fact  that  in 
the  knee,  hand,  elbow,  and  other  joints  there  are  occasionally  met  hernia- 
like protrusions  of  the  synovial  membrane  of  the  joint  cavity  through  the 
ligaments.  These  become  distended  with  fluid,  and  cause  some  stiffness, 
though  there  need  be  no  effusion  into  the  joint  proper.  Surgical  inter- 
ference with  such  tumors  is  very  apt  to  be  followed  by  general  synovitis, 
unless  asepsis  is  rigidly  observed. 

TpwEAtment. — The  localized  thecal  cyst  is  treated  by  sudden  pressure 
causing  subcutaneous  rupture,  or  by  subcutaneous  puncture  and  discis- 
sion with  a  tenotome.  The  fluid  thus  distributed  through  the  cellular  tis- 
sue becomes  absorbed.     Firm  pressure  made  by  the  surgeon's  thumbs  will 

12 


178  MUSCLES,    TENDONS    AND    BURS^. 

rupture  the  sac  unless  the  wall  is  quite  thick.  If  this  man(euvre  does  not 
succeed,  it  is  proper  to  introduce  a  tenotome  obliquely  through  the  skin  at 
a  sliort  distance  from  the  tumor,  and  then  puncture  the  sac  and  cut  the 
wall  in  various  directions  by  means  of  the  single  cutaneous  opening.  The 
fluid  is  thus  liberated  into  the  cellular  tissue,  or  pressed  out  through  the 
cutaneous  opening,  and,  as  the  sac  is  freely  divided,  there  is  little  liability 
of  its  reforming.  The  old-fashioned  method  of  striking  tlie  tumor  with  a 
heavy  book  iscrude,  and  withal  unsurgical,  because  severe  contusions  may 
be  caused.  The  limb  should  be  kej)t  at  rest  after  the  operation,  and  firm 
pressure  made  by  an  elastic  bandage,  or  by  an  ordinary  bandage  and 
compress  for  several  days.  The  external  ap])lication  of  blisters  and  iodine 
to  such  tumors  is  generally  of  no  service. 

If  rupture  or  subcutaneous  incision  does  not  cure  these  simple  thecal 
cysts,  and  they  are  the  cause  of  sufficient  disability  to  justify  a  more 
extended  operation,  it  is  i)roper  to  inject  tincture  of  iodine,  carbolic  acid 
or  other  irritating  fluid,  to  lay  them  open  freely,  and  paint  the  interior 
with  undiluted  carbolic  acid,  or  to  excise  them. 

These  procedures  are  more  serious  in  the  order  in  which  they  are 
named,  because  there  is  a  possibility,  though  scarcely  a  probability,  of 
causing  violent  inflammation  of  the  tendon  and  secondary  impairment  of 
function.  If  there  is  no  communication  between  the  cavity  of  the  cyst 
and  the  sheath  of  the  tendon,  this  danger  is  reduced  to  a  minimum,  but  it 
is  often  impossible  to  distinguish  the  fact  of  such  absence. 

Compound  thecal  cysts  cause  considerable  interference  with  the  use  of 
fingers  or  toes,  and,  therefore,  constitute  a  greater  disability  than  the 
simple  cysts.  They  are  also  more  serious  to  treat,  because  of  their  free 
communication  with  the  general  synovial  cavity  of  the  sheath.  Free 
incision,  occasionally  in  more  than  one  place,  with  complete  evacuation 
of  the  seed-like  bodies  and  absolute  rest  of  the  part,  is  probably  the  best 
treatment.  Some  operators  prefer  to  use  a  trocar  to  withdraw  the  con- 
tents, and  then,  after  washing  out  the  cavity  with  antiseptics,  inject  iodine 
or  some  other  irritant.  As  the  danger  of  operation  lies  in  putrefaction 
and  burrowing  of  pus  along  the  tendons,  I  am  inclined  to  favor  a  free 
incision  with  aseptic  or  antiseptic  dressings  to  small  punctures  or  the  use 
of  setons. 

Inflammation  of  a  Bursa  or  Bursitis,  and  Bursal  Tumors. 

Pathology. — In  connection  with  aflfectious  of  the  tendons,  diseases  of 
the  vesicular  synovial  membranes,  or  sacs  called  bursre,  must  be  consid- 
ered. Bursie  normally  exist,  as  a  rule,  where  a  tendon  or  the  integument 
slides  over  a  bony  prominence  ;  but  they  may  become  advantageously 
developed  wherever  constant  pressure  and  friction  call  for  protection  of 
the  underlying  structures.  The  normal  burste  number,  it  is  said,  about 
one  hundred  and  fifty,  and  are  found  principally  in  the  extremities.  The 
most  important,  surgically,  are  those  found  over  the  patella,  olecranon, 
great  trochanter,  tuberosity  of  the  ischium,  and  heads  of  the  first  and  fifth 
metatarsal  bones.  The  bursal  sacs  in  the  popliteal  space,  under  the  liga- 
ment of  the  patella,  under  the  psoas  and  iliac  tendons  as  they  cross  the 
pelvic  brim,  over  the  acromion,  between  the  angle  of  the  scapula  and 
broad  dorsal  muscle,  beneath  the  deltoid,  and  under  the  four-headed  ex- 
tensor muscle  of  the  leg,  should  be  remembered.  Inflammatory  afifections 
of  these  bursas,  though  somewhat  unusual,  are  liable  to  occur,  and  may 


INFLAMMATION    OF    A    BUESA.  179 

prove  confusing  to  the  surgeon.  Occasionally  a  transmitted  arterial 
impulse  causes  bursal  tumors  in  some  of  these  localities  to  bear  a  slight 
resemblance  to  aneurism. 

Adventitious  bursas  are  often  developed  at  the  points  of  pressure  in 
club-foot  and  other  distortions,  and,  indeed,  wherever  the  occupation  of 
the  man  or  woman  causes  more  or  less  constant  pressure. 

Bursitis,  or  inflammation  of  the  bursal  sac,  may  arise  from  injury  or 
from  constitutional  conditions,  such  as  gout,  rheumatism,  and  syphilis. 
The  inflammation  may  be  acute  or  chronic,  and  may  be  followed  by  sup- 
puration or  by  distention  with  dropsical  eff'usions. 

Symptoms. — Acute  is  not  as  common  as  chronic  bursitis.  The  symp- 
toms are  those  of  acute  inflammation  limited  to  the  known  situation  of  a 
bursal  sac,  with  some  distention  of  the  sac  by  increased  effusion  of  fluid. 
A  slight  crepitation  may  at  times  be  felt  with  the  first  symptoms  of  pain 
before  swelling  occurs.  The  immediately  adjacent  structures  are  cedema- 
tous,  and  there  is  often  considerable  constitutional  disturbance. 

The  sac,  when  distended  with  inflammatory  fluids,  forms  a  fluctuating 
tumor.  Suppuration  may  be  supposed  to  have  occurred  when  high  con- 
stitutional disturbance  has  persisted  for  some  time,  or  there  have  been 
rigors.  The  pus  may  make  its  exit  from  the  bursa,  or  suppurative  in- 
flammation in  the  neighboring  cellular  tissue  may  occur  without  actual 
rupture  of  the  sac  until  the  skin  and  deep  fascia  covering  the  knee,  for 
example,  are  completely  undermined  by  the  burrowing  matter.  In  time 
neglected  cases  will  point  externally,  leaving,  perhaps,  fistulous  tracts  or 
ulcerated  openings.    Sloughing  of  the  tissues  overlying  a  bursa  may  happen. 

Chronic  bursitis  is  more  usual,  and  is  characterized  by  much  less  pain, 
perhaps  a  mere  feeling  of  stiffness  or  weakness  of  a  limb,  and  by  marked 
distention  and  thickening  of  the  sac  until  a  smooth,  ffuctuating,  more  or 
less  globular  tumor  is  developed. 

The  serous  fluid  contained  in  the  cystic  tumor,  for  such  it  practically 
is,  may  be  quite  dark  from  disorganized  blood-cells,  and  frequently  ex- 
hibits rice-like  or  melon-seed  bodies  identical  with  those  described  in  the 
section  on  thecal  cysts.  The  amount  of  fluid  may  exceed  a  half-dozen 
fluidounces. 

Sometimes  the  walls  of  a  bursa  undergo  a  chronic  inflammatory  change 
which,  by  thickening  and  deposit  of  lymph,  converts  the  sac  into  a  hard, 
fibrous-like  tumor,  with  perhaps  a  small  central  cavity. 

The  most  frequent  location  of  bursitis  is  the  bursa  lying  over  the  pa- 
tella, which  is  frequently  subjected  to  traumatic  influences,  especially  in 
housemaids  and  others  whose  calling  requires  the  kneeling  posture.  This 
bursa  extends  downward  over  the  upper  part  of  the  ligament  of  the 
patella  and  thus  receives  many  impacts  that  the  patella  itself  escapes,  for 
it  is  well  known  that  in  kneeling  much  of  the  weight  comes  in  the  situa- 
tion of  ligament  of  the  patella  and  the  head  of  the  tibia  and  not  on  the 
patella  itself. 

Bursitis  is  to  be  distinguished  from  arthritis  of  the  adjacent  joint  by 
the  localized  nature  of  the  swelling  and  fluctuation,  the  less  interference 
with  motion,  the  absence  of  the  characteristic  semi-flexed  position  due  to 
synovial  effusion  in  joints,  and  the  comparative  ease  with  which  the 
normal  articular  prominences  can  be  seen.  Synovitis  of  the  knee-joint 
causes  the  patella  to  float  upon  the  effused  fluid  so  that  it  is  raised  from 
the  surface  of  the  condyles  of  the  femur.  If  the  surgeon  strikes  with 
his  fingers  upon  the  skin  over  the  patella  he  can  feel  the  patella  descend 
through  the  fluid  and  come  in  contact  with  the  femur.     This  test  shows 


180  MUSCLES,    TENDONS    AND    BURS^. 

in  cases  of  inflamraation  at  the  knee  whetlier  tlie  swelling  present  is  due 
to  fluid  below  the  patella  and  in  the  joint  or  to  serous  eHiision  above  the 
bone  in  the  bursa. 

Slight  inflammation  of  the  joint  occasionally  takes  place  as  an  accom- 
paniment of  bursitis  because  of  the  proximity  of  tissues.  If  the  bursa 
ruptures  and  allows  pus  to  enter  the  joint,  acute  arthritis  may  readily 
result. 

Treatment. — The  treatment  of  acute  bursitis  should  be  rest  of  the 
limb,  accomplished  by  elevation  and  splints,  and  the  application  of  ano- 
dyne or  refrigerant  lotions.  Leeches  may  be  of  service.  In  subacute 
cases  or  in  the  earliest  stage  of  acute  inflammation  a  blister  may  be  ap- 
plied. If  suppuration  is  suspected  an  early  and  free  incision  followed  by 
curetting  is  proper,  because  the  danger  of  burrowing  of  pus  and  pro- 
tracted convalescence  is  great.  It  is  probably  preferable  in  })atellar  bur- 
sitis to  make  the  incision  a  little  to  one  side  of  the  median  line,  in  order 
that  the  cicatrix  may  not  be  so  subject  to  pressure  after  cure  has  been 
obtained.  Sloughing  of  soft  parts  and  caries  of  the  patella  must  be 
treated  on  general  principles. 

If  spontaneous  evacuation  of  pus  and  burrowing  have  taken  place 
before  the  case  comes  to  the  attendant,  the  sinuses  must  be  laid  open  and 
all  pouches  must  be  washed  out  with  betanaphthol  or  sublimate  solution 
or  carbolized  water,  and  emptied  by  counter-openings  or  drainage. 

Chronic  inflammation  or  dropsy  of  a  bursa  is  to  be  treated  by  counter- 
irritation  and  elastic  pressure.  If  this  fails,  as  it  usually  will,  tapping 
with  a  trocar  or  aspirator,  followed  by  the  injection  of  strong  carbolic 
acid  solutions  or  iodine  tincture,  or  by  pressure,  should  be  adopted.  Lay- 
ing open  the  sac  and  keeping  it  stuflJed  with  antiseptic  gauze,  thus  causing 
granulation  and  obliteration  to  occur,  is  an  available  method.  After 
laying  open  the  sac  the  interior  may  be  mopped  with  some  strong  caustic, 
as  carbolic  or  nitric  acid.  Solid  bursal  tumors  must  be  dissected  out. 
Care  is  required  to  avoid  injuring  the  adjacent  synovial  lining  of  the 
joint. 

Bunion. 

When  a  normal  or  an  adventitious  bursa  upon  the  toes  becomes  in- 
flamed the  condition  called  bunion  is  said  to  exist.     Bunions  are  usually 
secondary  to  displacement  of  and  pressure  upon  the  toes,  arising  from 
muscular  and  osseous  derangement  and  the  wearing  of 
Fig.  70.  iH-fitting  shoes. 

The  metacarpo-phalangeal  joint  of  the  great  toe  is 
the   most   frequent  seat  of  bunion.     This  toe  is  very 
liable   to   a   chronic  subluxation    at   this    joint,   and 
thus  becomes  bent  toward  the  middle  line  of  the  foot. 
Upon  the  prominence  made  at  the  distorted  joint  by 
the  head  of  the  metacarpal  bone  a  bursa  is  developed 
by  the  pressure  of  the  shoe.    When  this  bursa,  or  the 
normal  one  situated  nearer  the  plantar  surface  of  the 
joint,  becomes  irritated  and  inflamed,  a  bunion  exists. 
Distortion  of  toe  and         I*  is  said  that  this  deformity  of  the  great  toe  is  due 
bunion.  (Bryant  )      ^0  wearing  narrow  and  short  shoes,  but  this  is  probably 
untrue,  since  marked  subluxation  is  exceedingly  com- 
mon in  the  lower  classes,  Avho  do  not  take  pride  in  exhibiting  small  feet. 
A  more  probable  explanation  is  that  of  Key,  who  believes  it  due  to  exces- 


BUNION. 


181 


Fig.  71. 


sive  standing  which,  Avhen  the  arch  of  the  foot  is  weak,  causes  distortion 
because  of  the  obliquity  of  the  pressure  upon  the  inner  side  of  the  sole. 

Tight  shoes  cause  the  development  and  the  inflammation  of  the  bursa, 
and  thus  lead  to  the  bunion,  but  probably  do  not  act  as  the  primary 
cause  of  the  deformity. 

Club-feet  usually  have  bursse  developed  upon  their  prominences,  but 
even  if  these  burs?e  imflame  they  are  seldom  dignified  by  the  special  title 
bunion. 

The  skin  over  a  bunion  may  have  a  corn  developed  upon  it,  which,  of 
course,  increases  the  painfulness  of  the  affection.  A  bunion  may  suppu- 
rate, leaving  a  foul  ulcer  or  fistulous  opening ;  may  open  into  the  joint 
cavity,  causing  arthritis  and  disorganization 
of  the  articulation  ;  or  may,  in  decrepit  pa- 
tients, be  the  starting-point  of  erysipelas  or 
gangrene.  The  preventive  treatment  of  bunion 
consists  in  maintaining  the  correct  axis  of  the 
toe,  and  restoring  it  when  deflection  first  oc- 
curs. The  first  is  to  be  done  by  avoiding  con- 
tinuous standing  during  youth,  and  wearing 
shoes  with  flat  heels  and  broad  soles,  and  al- 
most straight  along  the  inner  edge.  The  true 
Waukenphast  pattern  fulfils  these  indications. 
Restoration  of  a  distorted  toe  may  be  accom- 
plished by  steel  springs  and  elastic  traction,  so 
arranged  as  to  be  worn  constantly. 

Tenotomy  of  muscles  which  act  as  dis- 
placing causes,  division  of  the  ligaments,  ex- 
cision of  the  joint,  or  amputation  of  the  toe 
may  be  justifiable  if  the  deformity  and  the 
resulting  inflammation  and  necrosis  cause 
great  disability. 

The  bursitis  must  be  managed  by  rest,  ele- 
vation of  the  foot,  anydyne  lotions,  painting 

with  nitrate  of  silver  or  tincture  of  iodine,  and  the  local  and  general 
measures  detailed  in  the  chapter  on  Inflammation. 

The  formation  of  pus  requires  an  incision,  but  in  all  operations  in  this 
region  in  old  and  debilitated  patients  it  must  be  remembered  that  the 
circulation  here  is  feeble,  and  that  unhealthy  inflammation  and  gangrene 
are  not  unusual  after  surgical  interference.  The  treatment  of  bunion,  then, 
is  identical  with  that  of  inflamed  burs?e  elsew^here. 

A  radical  cure  can  sometimes  be  effected  by  introducing  a  tenotome  at 
a  distance  and  cutting  up  the  bursal  sac,  as  is  occasionally  done  in  thecal 
cysts.  Laying  open  the  sac  by  a  free  incision  or  excising  it  may  at 
times  be  justifiable  operations. 


Bigg's  apparatus  tor  replacing 
toe. 


CHAPTEK    XY. 

DISEASES  AND    INJURIES  OF    THE    NERVOUS  CENTRES  AND 

NERVES. 

DISEASES   AND    INJURIES   OF   THE    I5RAIN. 


Meningocele  and  Encephalocele. 

These  are  congenital  tumors  due  to  the  protrusion  of  a  poition  of  the 
meninges  in  the  one  case,  and  of  a  part  of  the  encephalon  and  its  cover- 
ings in  the  other  case,  through  an  opening  in  the  cranial  bones.  The  pro- 
trusion may  occur  at  a  suture,  a  fontanelle,  or  an  abnormal  orifice  in  the 
skull.     The  most  common  seats  for  such  unusual  tumors  are  the  occipital 

and  fi'ontal  regions.     In  pathology 
Fk;.  72.  these  tumors  resemble  hydrorachis 

or  bifid  spine. 

A  meningocele  being  a  pouch 
of  brain-membranes  containing 
sub-arachnoid  fluid,  resembles  a 
cystic  tumor  of  ordinary  kind. 

Encephalocele  is  often  asso- 
ciated with  other  congenital  mal- 
formations, and  usually  is  more 
solid  than  the  tumor  just  de- 
scribed. 

Asa  fatal  issue  generally  occurs 
in  these  congenital  hernias  of  the  brain  and  its  membranes,  encephalocele 
and  meningocele  are  of  little  importance  except  that  the  surgeon  must 
think  of  them  when  diagnosticating  tumors  of  the  head. 

Their  j)artial  or  complete  reducibility,  their  immobility,  the  location  of 
the  neck  of  the  tumor  upon  the  cranial  bones,  the  variation  in  distention 
as  the  child  is  quiet  or  excited,  and  in  encephalocele,  the  occasional  ex- 
istence of  pulsation,  will  aid  in  the  diagnosis. 

Pressure,  aspiration,  ligation,  and  excision  are  methods  of  treatment 
indicated,  but  are  in  most  instances  valueless. 


Meuinjiructile. 


Hydrocephalus. 

Hydrocephalus  is  a  dropsical  condition  of  the  brain,  consisting  of  an 
abundant  accumulation  of  serous  fluid  in  the  ventricles  or  the  arachnoid 
space,  or  in  both.  It  is  a  chronic  condition,  usually  occurring  as  a  con- 
genital disease.  Acute  hydrocephalus,  so  called,  is  of  different  pathology, 
for  the  term  is  variously  applied  by  authors  to  tubercular  meningitis  and 
to  cerebral  dropsy  due  to  renal  disease.  The  amount  of  fluid  in  chronic 
hydrocephalus  varies  from  half  a  pint  to  several  pints,  and  produces 
enlargement  of  the   head,  especially  in  the   antero-posterior   diameter, 


IXFLAMMATIOiNr    OF    THE    BRAIN".  183 

spreading  of  the  sutures  and  thinning  of  the  cranial  bones.  The  pecu- 
liar squareness  of  the  cranium  and  relatively  small  face  give  the  child  a 
characteristic  appearance.  The  inti'acranial  pressure  and  want  of  brain 
development  cause  lack  of  intelligence,  paralysis,  convulsions,  retinal 
changes,  and  other  cerebral  symptoms.  There  is  apparently  little  pain 
felt  by  the  infant. 

The  most  improved  remedies  are  mercury  and  iodide  of  potassium, 
which  have  at  times  seemed  to  yield  good  results.  Early  death  follows 
hydrocephalus,  as  a  rule,  when  the  dropsy  is  great  and  situated  in  the 
ventricles.  Dropsy  located  in  the  cerebral  membranes  has  a  more  favor- 
able prognosis. 

Tapping  the  distended  skull  with  the  aspirator,  whether  or  not  followed 
by  injections  of  dilute  tincture  of  iodine,  has  not  been  very  satisfactory. 
It  is  better  to  repeat  the  tapping  than  to  attempt  to  evacuate  all  the 
serum  at  once,  and  the  fluid  should  each  time  be  drawn  ofl"  slowly.  The 
instrument  should  not  be  introduced  in  the  median  line  of  the  sagittal 
suture  because  the  suj^erior  longitudinal  sinus  would  be  punctured.  The 
wide  separation  of  the  bones  gives  opportunity  to  pierce  the  cranium  at 
one  side  of  the  median  line.  Moderate  pressure  by  an  elastic  bandage 
may  be  employed  after  tapping,  or  even  as  an  independent  treatment. 

If  convulsions  occur  during  the  progress  of  the  disease,  bromide  of 
potassium  is  the  proper  remedy. 

Intentional  puncture  of  the  ventricles  themselves  has  been  done  by 
Keen  in  a  case  of  hydrocephalus.  Death  finally  occurred  after  apparent 
benefit  from  the  operation. 

Inflammation  of  the  Brain  from  Surgical  Causes. 

Varieties. — Inflammation  of  the  cranial  contents  is  termed  encephali- 
tis. The  pathological  process  may  be  located  in  the  meninges  or  mem- 
branes (meningitis),  in  the  nervous  tissue  composing  the  various  parts  of 
the  brain  (cerebritis),  or  may  involve  both  structures  (meningo-cere- 
britis). 

These  three  conditions,  therefore,  are  merely  varieties  of  encephalitis 
or  intracranial  inflammation.  It  is  rare  to  find  severe  meningitis  with- 
out some  involvement  of  the  underlying  brain  substance ;  and,  unless  the 
cerebritis  is  limited  to  the  deep  parts  of  the  brain,  local  meningitis,  at 
least,  is  a  usual  accompaniment  of  inflammation  of  the  nerve  tissue. 
Cerebritis  strictly  should  not  include  inflammation  of  the  cerebellum,  to 
which  the  term  cerebellitis  ought  to  be  applied. 

Pathology. — In  meningitis  inspection  of  the  membranes  shows  vascular 
engorgement  of  the  dura  mater  and  pia  mater,  cloudiness  or  opacity  of 
the  arachnoid,  and  greenish  or  yellowish  lymph  deposited  upon  and  between 
the  membranes.  The  arachnoid  membrane  and  its  cavity  show  with 
most  frequency  the  existence  of  pathological  changes  ;  but  puriform  lymph 
and  pus  will  be  found  smeared  upon  the  dura  mater  or  in  the  meshes  of 
the  pia  mater  if  the  inflammation  reaches  a  high  grade.  The  relative 
position  of  these  morbid  deposits,  as  to  the  dura  and  pia  mater,  depends 
much  upon  the  starting-point  of  the  encephalitis.  Thickening  of  the 
membranes  occurs  with  the  progress  of  inflammation.  Cerebritis,  and 
the  term  is  used  to  signify  inflammation  of  the  cerebellum  and  pons  as 
well  as  of  the  cerebrum,  is  exhibited  by  increased  vascularity,  a  change 
in  color  from  gray  or  white  to  a  pinkish  or  dirty  yellow  or  a  leaden  hue, 


184      DISEASES    AND    INJURIES    OF    NERVOL'S    CENTRES. 

tui'bid  serum  in  the  ventricles,  and  softening  of  the  nerve  structure.  If 
the  disintegration  continues  pus  will  be  formed,  constituting  a  cerebral 
abscess,  which  may  contain  several  tiuidounces  of  fluid. 

Cause.s. — The  causes  of  surgical  encephalitis  are  fracture,  caries,  and 
necrosis  of  the  skull  involving  directly  or  indirectly  the  cranial  contents; 
wounds  of  the  membranes;  concussion,  contusion,  lacerations  and  other 
wounds  of  the  brain  ;  and  pyitMnia. 

Symptoms. — The  symptoms  of  meningitis  and  of  cerebritis  are  not,  as 
a  rule,  sufficiently  distinct  to  make  a  differential  diagnosis  possible. 
Fortunately,  their  treatment  would  be  identical  in  the  majority  of  cases, 
even  if  such  a  diagnosis  was  made.  .Vcute  traumatic  encephalitis  gives 
rise  to  headache,  pain,  and  elevation  of  surface  temperature  at  the  seat  of 
injury,  contracted  pupils,  intolerance  of  light  and  sounds,  restlessness, 
delirium,  general  fever,  full  and  frequent  pulse,  constipation  and  perhaps 
vomiting.  As  the  disease  progresses  twitching  of  the  muscles,  strabismus, 
convulsions,  stupor  increasing  to  absolute  coma,  and  relaxation  of  the 
sphincters  of  rectum  and  bladder  supervene.  Great  circulatory  depres- 
sion, as  shown  by  feeble,  irregular,  and  very  frequent  pulse,  clammy 
sweating  and  dilated  pupils  proclaim  serious  involvement  of  the  ])rain, 
which  will,  in  all  probability,  speedily  terminate  in  death.  The  paralytic 
symptoms  are  due  usually  to  the  exudation  of  inflammatory  products, 
which  cause  a  condition  similar  to  compression  from  extravasation  of 
blood  in  depressed  fracture.  Rigors  occasionally  happen  and  suggest  the 
formation  of  an  intracranial  abscess  or  of  pyaemic  infection  from  inflam- 
mation having  involved  the  diploic  structure  of  the  cranial  bones.  Sub- 
normal temperature  is  thought  to  be  indicative  of  abscess. 

Acute  encephalitis  occurs  in  from  one  to  three  days  after  the  receipt  of 
injury,  and  usually  leads  the  surgeon  to  believe  that  there  has  been  a 
general  injury  to  the  brain  in  addition  to  the  evident  local  lesion.  In 
other  words,  symptoms  of  acute  encephalitis  generally  mean  contusion  or 
laceration  of  one  or  more  parts  of  the  brain  distant  from  the  point  of 
impact  with  the  vulnerating  body.  Laceration  by  counter-stroke  at  the 
side  opposite  the  injury  is  a  not  unusual  factor  in  the  etiology  of  acute 
inflammation. 

The  condition  occurring  after  injuries  and  called  irritation  of  the  brain 
is  probably  a  minor  degree  of  encephalitis  affecting  special  regions  of  the 
brain  substance.  It  is  characterized  by  restlessness  of  the  patient,  who 
lies  curled  up  on  one  side  with  his  limbs  flexed  and  his  eyes  tightly 
closed.  If  aroused  from  his  semi-insensibility  he  shows  a  momentary 
mental  irritability,  and  then  relapses  into  a  restless  sort  of  sleep. 

Chronic  encephalitis  causes  headache,  vertigo,  hebetude  and  intellectual 
dulness,  insomnia,  ej)ileptiform  seizures,  choking  of  the  optic  disks  or 
papillitis,  paralysis,  and  coma.  The  symptoms  are  less  violent  than  in 
acute  inflammation,  but  are  similar,  though  coming  on  insidiously  and  at 
a  period  varying  from  weeks  to  months.  Pain  at  the  seat  of  injury  and 
a  local  rise  in  surface  temperature  are  grave  symptoms  in  old  head  in- 
juries. 

Death  occurs  in  encephalitis  from  pressure  due  to  morbid  deposits  or 
from  blood  extravasated  from  diseased  vessels ;  from  destruction  of  ner- 
vous centres  by  softening  or  abscess;  from  interference  with  blood-supply 
by  thrombosis,  and  from  pytemic  injection  of  the  general  system. 

A  diagnosis  between  meningitis  and  cerebritis  is,  as  a  rule,  impossible, 
because  the  two  conditions  are  so  frequently  associated  that  we  are  not 
assured  of  the  symptoms  pertaining  exclusively  to  each.    If  the  local  pain, 


INFLAMMATION    OF    THE    BEAIN.  185 

the  restlessness,  nausea,  and  hypersesthesia  of  the  optic  and  auditory 
nerves  are  especially  marked,  it  is  probable  that  inflammation  of  the 
meninges  is  the  prominent  pathological  change.  Cerebritis  is  to  be  sus- 
pected if  convulsions,  jerking  of  the  muscles,  trembling,  and  sudden  dis- 
turbances of  the  special  senses  are  observed.  The  suspicion  is  strength- 
ened if  the  muscular  symptoms  are  unilateral,  and  if  coma  and  actual 
paralysis  of  one  side  rapidly  occur. 

Treatment. — Acute  inflammation  of  the  brain  requires  active  treat- 
ment. The  entire  scalp  should  be  shaved  to  permit  full  examination  for 
fracture,  contusion,  or  other  injury;  the  head  should  be  elevated,  cold 
should  be  applied  to  the  cranium  by  means  of  a  bladder  or  rubber  bag 
containing  cracked  ice,  or  by  means  of  cold  water  passing  through  a  coil 
of  tubing  encircling  the  head  several  times,  and  the  patient  should  be 
kept  in  a  darkened  and  quiet  room.  If  the  pulse  is  hard  and  frequent, 
the  face  flushed,  and  the  carotid  arteries  evidently  carrying  a  large 
amount  of  blood  to  the  head,  venesection  at  the  bend  of  the  arm  is  valu- 
able. The  bleeding  should  be  supplemented  by  free  purging,  large  doses 
of  bromide  of  potassium  (giij  to  3v  in  twenty-four  hours)  and  cardiac  de- 
pressants, such  as  tincture  of  aconite  root  (n\^j  to  iij  every  two  or  three 
hours),  or  tincture  of  veratrum  viride  (rti^j  to  iij  every  two  or  three  hours). 
The  best  purgatives  are  calomel  and  jalap  (gr.  v  to  x  each),  or  two  or 
three  compound  cathartic  pills.  Many  do  not  require  bleeding,  but  are 
judiciously  treated  by  the  other  remedies  mentioned,  with  or  without  wet 
cupping  at  the  nape  of  the  neck.  Digital  or  instrumental  pressure  upon 
the  carotid  arteries  has  been  suggested  as  a  means  of  diminishing  the 
intracranial  circulation.  Some  high  authorities  advise  the  use  of  mer- 
curials and  opiates  to  combat  encephalitis,  and  give  calomel  (gr.  5)  and 
morphia  (gr.  yij-)  every  few  hours,  for  their  antiphlogistic  and  quieting 
effect.  I  have  been  accustomed  rather  to  rely  upon  the  revulsive  action 
of  purgative  doses  of  mercury  and  other  drugs,  and  the  cerebral  anaemia 
and  quiet  produced  by  large  doses  of  bromide  of  potassium.  When  there 
are  great  restlessness  and  brain  irritability,  morphia  in  moderate  doses  is 
indicated.  Chloral  (gr.  v  to  xv)  or  hyoscine  hydrobromate  (gr.  -jjjj) 
may  be  employed  to  meet  this  symptom.  The  diet  should  be  limited  in 
quantity,  and  restricted  to  milk  or  other  non-stimulating  food. 

In  the  later  stages,  when  exudation  has  probably  occurred,  blisters  may 
be  used  locally,  and  iodide  of  potassium  (gr.  v  to  x)  and  mercury  (green 
iodide,  gr.  i  to  ^)  given  internally  several  times  in  the  twenty-four  hours. 

When  great  depression  supervenes  some  alcoholic  stimulant  may  be 
employed,  but  usually  this  stage  presages  death,  which  cannot  be,  and  per- 
haps could  not,  have  been  averted.  In  all  cases  the  bladder  should  be 
watched,  and  catheterized  if  the  urine  is  not  passed.  The  patient  is  per- 
haps unconscious,  and  the  attendants  may  neglect  to  call  attention  to  the 
fact  that  no  urine  has  been  passed  unless  the  surgeon  makes  inquiries. 

Subacute  and  chronic  encephalitis  demand  similar  though  less  active 
treatment.  The  measures  mentioned  for  the  later  stages  of  the  acute 
disease  are  especially  applicable.  Mercury,  iodide  and  bromide  of  potas- 
sium, blisters,  and  laxatives  are  usually  employed.  If  an  acute  inflam- 
mation is  engrafted  upon  a  chronic  one,  it  must  be  met  by  active  and 
vigorous  measures,  as  though  it  had  been  an  acute  affection  primarily. 

In  all  cases  of  suspected  brain  disease  the  condition  of  the  urine  should 
be  investigated,  since  renal  changes  will  induce  urajmic  symptoms,  simu- 
lating intracranial  inflammation. 

Patients  who  have  recovered  from  encephalitis  due  to  surgical  causes. 


186      DISEASES    AND    INJURIES    OF    NERVOUS    CENTRES. 

may  suffer  for  many  weeks  from  vertigo,  headache,  sleeplessness,  mental 
aberration,  and  other  se(juels  pointing  to  deranged  nervous  activity. 
These  symptoms  are  to  be  combated  by  the  long-continued  use  of  altera- 
tives, such  as  the  preparations  of  mercury  and  iodine,  and  by  the  tem- 
porary administration  of  bromide  of  potassium,  chloral  hydrate,  and 
similar  medicines. 

Chronic  encej)halitis  is  a  not  uncommon  symptom  of  tertiary  syphilis, 
and  is  frequently  associated  with  syphilitic  inflammation  of  the  spinal 
cord.  ]\Iercairy  (green  iodide  gr.  j  to  gr.  ij,  during  twenty-four  hours), 
with  iodide  of  potassium  (gr.  Ixxv  to  gr.  c  in  twenty-four  hours),  is 
especially  indicated  in  such  cases.  All  chronic  cases  should  be  subjected 
to  antisyphilitic  treatment,  as  should  all  cases  of  su[)posed  brain  tumor. 

Oi'KHATiVK  Tkeatmext. — When  it  is  possible  to  locate  the  exact  seat 
of  the  intracranial  inflammation,  operative  interference  may  sometimes 
be  undertaken  with  the  hope  of  removing  the  spicule  of  bcme  or  the 
foreign  body  which  has  caused  and  is  keeping  up  the  morbid  process,  or 
with  the  expectation  of  evacuating  the  collection  of  blood  or  pus  which  is 
threatening  the  life  of  the  patient. 

Trephining  the  skull,  incising  the  membranes  and  puncturing  the  hram 
tissue  are  the  modes  of  operation  that  may  be  adopted.  Such  procedures 
are  much  more  frequently  justifiable  in  chronic  than  in  acute  encephalitis, 
because  the  former  is  more  likely  to  be  local  in  its  causation  and  in  its 
lesions,  and,  therefore,  more  accessible  by  operation.  The  reader  must 
recollect  that  in  this  connection  I  am  speaking  of  trephining  as  a  mode  of 
treating  existing  traumatic  inflammation  of  the  brain,  and  not  of  preven- 
tive trephining,  which  is  undertaken  to  prevent  the  consec^uences  of  punc- 
tured and  other  forms  of  fracture  of  the  cranium.  The  method  of  using 
the  trephine  will  be  described  under  fractures  of  the  skull. 

Operation  may  be  done  to  give  exit  to  an  extravasation  of  blood  or 
a  purulent  collection  within  the  cranial  cavity  ;  to  remove  a  foreign  l)ody, 
such  as  a  bullet,  supposed  to  be  buried  in  the  brain  or  membranes,  and 
to  endeavor  to  find  and  get  rid  of  the  cause  of  an  inflammation  which  is 
suspected  to  be  due  to  a  splintered  condition  of  the  inner  table  or  to 
localized  bone  disease. 

Collections  of  pus  or  of  blood  may  lie  between  the  bones  and  membranes 
(subcranial),  in  natural  or  abnormal  cavities  formed  between  layers  of 
membranes  (intermeningeal),  or  in  the  substance  and  ventricles  of  the 
brain  (cerebral).  Subcranial  and  cerebral  extravasations  and  abscesses 
are  usually  circumscribed,  and,  therefore,  more  amenable  to  operative 
treatment  than  intermeningeal  collections,  which  are,  as  a  rule,  diffused. 

Localization  of  Brain  Lesions. — Lentil  within  a  few  years  the  sur- 
geon had  little  to  guide  him  in  attempts  at  ascertaining  the  precise  loca- 
tion of  cerebral  lesions ;  and,  therefore,  operations  upon  the  skull  and 
brain  were  seldom  justifiable  in  eases  where  there  was  no  fissure  or  open- 
ing in  the  cranium.  A  localized  pufty  swelling  of  the  scalp,  or  separation 
of  the  pericranium  exposing  yellowish  or  dry  bone,  with  hemiplegia  of 
the  opposite  side  of  the  body,  and  especially  if  rigors  had  occurred,  might 
induce  a  bold  operator  to  trephine  and  endeavor  to  evacuate  the  abscess  ; 
but  there  were  no  rules  founded  on  physiological  and  clinical  observation 
to  guide  him  in  the  less  obscure  cases. 

The  recent  study  of  cerebral  localization  by  Ferrier,  Charcot,  Horsley, 
and  other  neurologists,  however,  has  made  it  possible  to  determine  the  site 
of  many  lesions  of  the  cerebral  cortex,  or  surface,  by  the  local  tempera- 
ture and  the  character  of  the  paralytic  and   other  nervous   symptoms. 


INFLAMMATION    OF    THE    BRAIN. 


187 


The  special  symptoms  belonging  to  irritative  and  destructive  lesions  of  the 
various  parts  of  the  interior  of  the  brain  have  not  yet  been  established 
with  much  accuracy  ;  and,  indeed,  the  exact  locality  of  many  of  the 
nervous  centres  upon  the  surface  is  still  doubtful.  JN'evertheless,  enough 
has  been  done  in  this  direction  to  aid  the  surgeon  very  much  in  determin- 
ing, from  the  symptoms,  where  to  apply  the  trephine  in  suspected  abscess, 
extravasation,  or  imj)acted  splinters  of  bone. 

F!G.  73. 

SUPERrOR   FRONTAL  ri  S  5  U  R  E    0  ^  RO  LAN  O  0 

FISSURE 


INTERIOR 

TRONTAL    / 

n  SSU  RE 


FIS  SURE     OF 
S  V  L"V  I  U  S 

Diagram  of  skull,  showingr  relation  of  convolutions  to  bones. 


The  relation  of  the  important  landmarks  of  the  brain  to  the  external 
conformation  of  the  skull  is  found  in  the  figures. 

It  is  important  to  distinguish  lesions  of  the  surface  of  the  cerebral 
hemispheres  from  those  of  the  interior  of  the  brain,  because  the  former, 
unless  at  the  base,  are  more  easily  reached  by  operation.  Cortical  lesions 
cause  usually  not  a  loss  of  motion  of  an  entire  side  (hemiplegia),  but  a 
paralysis  of  only  a  special  group  of  muscles,  as  of  the  hand,  forearm,  or 
leg  (monoplegia),  and  there  is  quite  frequently  early  rigidity  of  the  same 
muscles.  Jacksonian  epilepsy,  or  convulsive  action  of  a  single  group  of 
muscles,  as  of  a  thumb,  occurring  alone,  or  occurring  as  a  prelude  to  a 
general  epileptiform  convulsion,  gives  indication  that  there  is  a  lesion  of 
that  particular  cortical  centre,  and  points  to  the  advisability  of  an  explora- 
tory operation  in  that  region.  Local  pain,  which  may  be  felt  only  when 
the  head  is  percussed  over  the  lesion,  is  also  a  symptom  of  cortical  disease, 
and,  finally,  unconsciousness  is  not  so  often  associated  with  the  paralysis 
from  cortical  lesions,  as  is  the  case  in  paralysis  from  lesions  of  the  central 
portion  of  the  brain. 

The  portions  of  the  cortex  in  which  the  nervous  centres  of  motion  are 
located  are  the  bases  of  the  three  frontal  convolutions,  the  convolutions 


188      DISEASES    AND    INJURIES    OF    NERVOUS    CENTRES. 

along  the  fissure  of  Kolando  and  the  paracentral  lobule,  while  the  centres 
of  sensation  seem  to  be  in  the  jiarietal,  temporal,  and  occipital  lobes  of  the 
cerebrum.  Recent  investitrations  go,  however,  much  further  than  this, 
and  locate  with  considerable  certainty  centres  g(jverning  many  special 
motions.  From  this  knowledge  it  is  possible  to  diagnosticate  witii  a  great 
degree  of  certainty  the  location  of  the  inflammatory  process  which  is  pro- 
lUicing  the  symptoms  in  a  given  case. 


Diagramofskull.showinglinesof  fissure  of  Rolando,  middle  meningeal  artery  and  cortical 

centres. 

The  symptoms  pertaining  to  lesions  of  limited  areas  still  require  further 
ditierentiation,  but  the  value  of  cerebral  localization  to  surgical  treatment 


Fig. 


Broca's  square. 


Broca's  square  applied. 


has  so  rapidly  increased  that  even  now  it  is  incumbent  upon  all  surgeons  to 
recognize  its  utility.     As  an  example,  let  me  state  that  paralysis  of  an  arm 


INFLAMMATION    OF    THE    BEAIN 


189 


alone  (bracliial  monoplegia)  indicates  disease  of  the  upper  part  of  the 
ascending  frontal  convolutions  of  the  opposite  side.  Here  then  would  be 
the  place  to  trephine,  if  the  other  symptoms  rendered  the  occurrence  of 
abscess  or  intra-cranial  bleeding  probable. 

It  is  always  important  to  determine  upon  the  shaved  head  the  location 
of  the  fissure  of  Rolando  before  undertaking  any  operative  procedure 
based  on  cerebral  localization.  This  may  not  be  necessary  if  an  external 
injury  or  scar  indicates  the  probable  seat  of  lesion.  This  fissure  has  its 
upper  end  50  or  55  millimetres  behind  the  bregma  or  junction  of  the  in- 
terparietal and  coroneal  sutures,  but  does  not  quite  reach  the  middle  line 
of  the  skull.  The  bregma  is  found  by  drawing  a  vertical  plane  through 
the  two  external  auditory  openings.  The  lower  end  of  the  Rolandic  fis- 
sure is  about  six  centimetres  above  and  a  little  behind  the  external  audi- 
tory canal.  It  makes  an  angle  of  67  degrees  with  the  median  line  drawn 
from  the  glabella,  or  smooth  spot  at  the  root  of  the  nose,  to  the  external 
occipital  protuberance,  or  inion,  and  has  its  upper  end  beginning  on  a  line 
with  a  spot  situated  55  j^  per  cent,  of  the  total  distance  from  the  glabella 
to  the  inion.  The  illustrations  show  two  methods  of  determining  the 
location  of  the  Rolandic  sulcus:  that  by  Broca's  square  and  that  by 
Wilson's  cyrtometer. 

Fig.  77. 


B    55Tn-ia 


AOE 


Diagram  showing  one  method  of  locating  the  fissure  of  Eolando.     (Naxceede.) 

Some  general  rules  may  be  formulated  that  are  well  worth  attention.^ 

In  injury  or  disease  in  the  neighborhood  of  the  fissure  of  Rolando, 

which  is  the  motor  region,  operation  is  indicated  Avhen  monoplegia  is 

present,  except  when  anaesthesia  accompanies  the   paralysis  of  motion ; 

then  it  is  contraindicated,  because  the  lesion  is  evidently  so  extensive 


1  See  Operative  Surgery  of  the  Human  Brain,  by  John  B.  Eoberts.     Also  papers  of  C. 
K.  Mills  and  Eoswell  Park  in  Trans.  Congress  of  American  Phvsicians  and  Surgeons, 

vol.  i.  1889. 


190      DISKASES    AND    INJURIES    OF    NERVOUS    CENTRES. 

that  sensory  as  well  as  motor  centres  are  involved.  When  paralysis  or 
convulsive  niovenients  occur  in  connection  with  disease  of  the  sensory 
region,  operative  interference  is  improper,  since  the  pathological  change  is 
not  limited  to  the  sensory  centres,  but  involves  the  motor  region.  An 
exploratory  tre]ihining,  if  properly  carried  out  with  antiseptic  precau- 
tions, is  so  devoid  of  danger  that  many  surgeons  would  operate  notwith- 
standing the  co-e.xistence  of  motor  and  sensory  symptoms. 

Paralvsis  on  the  same  side  as  the  injury  of  the  head  should  be  consid- 
ered an  indication  against  operation  at  the  point  of  injury,  ])ecause  there 
is  probably  a  lesion  at  the  opposite  side  of  the  brain,  due  to  counter-stroke. 
Ao-ain,  very  profound  loss  of  motion  points  to  non-interference,  because 
it  is  likely  that  the  injury  involves  deeper  tissues  than  the  cortical  cen- 
tres of  motion.  Paralysis  of  the  cranial  nerves,  Cheyne-Stokes  respira- 
tion, choked  disk,  and  symptoms  referable  to  injury  of  the  base  of  the 
brain  contra-indicate  surgical  procedures. 


Fig.  78. 


Wilson's  cyrtometer,  consisting  of  a  steel  tape  to  encircle  the  cranium  and  sliding  upon 
it  another  tape  making  with  it  an  angle  of  67°.  Both  tapes  are  marke<l  with  a  scale. 
(Park.) 

The  occurrence  of  aphasia  betokens  an  abscess,  pressure  from  a  clot, 
or  injury  from  a  spicule  of  bone,  located  near  the  base  of  the  third 
frontal  convolution  and  the  island  of  Reil,  and  usually  on  the  left  side. 
Right-sided  loss  of  motion  in  addition  to  the  aphasia,  while  showing  a 
more  extensive  lesion,  perhaps,  fixes  the  lesion  at  the  left  side  of  the  brain. 
In  such  cases  trephining  gives  a  reasonable  hope  of  reaching  and  remov- 
ing the  cause  of  the  threatening  symptoms. 

When  the  symptoms  and  principles  just  discussed  furnish  sufficiently 
clear  evidence  to  satisfy  the  surgeon  as  to  the  probable  seat  of  the  lesion. 


INJURIES    OF    THE    BRAIN, 


191 


Fig.  79. 


it  is  proper,  if  the  case  present  a  serious  outlook,  to  trejjhine  without 
delay.  Delay  is  dangerous  if  the  lesion  is  chronic  encephalitis  with 
abscess ;  and  equally  so  if  there  are  symptoms  of  a  large  extravasation  of 
blood,  or  of  a  local  inflammation  due  to  spicules  of  bone.  After  the 
skull  has  been  bored  the  pus  or  blood 
will  be  evacuated  if  it  lies  between 
the  bone  and  dura  mater.  If  none  is 
found,  and  the  dura  bulges  into  the 
opening  and  does  not  show  pulsation 
an  incision  should  be  made  through 
this  membrane  with  the  object  of 
reaching  any  collection  beneath  it.  If 
the  symptoms  of  cerebral  abscess  have 
been  very  characteristic  and  death  is 
imminent  it  is  justifiable  to  puncture 
the  brain  in  various  directions  with 
an  aspirator  needle  or  grooved  direc- 
tor in  order  to  reach  the  purulent 
deposit.  In  the  event  of  discovering 
a  large  hemorrhagic  efi^usion  from  a 
meningeal  vessel,  torsion  of  the  artery 
may  be  required.  If  this  fails  a  tre- 
phine may  be  again  applied  over  the 
course  of  the  vessel,  and  a  ligature 
applied  after  removal  of  the  disk  of 
bone.  After  reaching  an  abscess  of 
the  brain  the  surgeon  must  be  on  the 
alert  to  keep  the  orifice  open  and  not 
let  it  become  closed  by  granulations. 
Injections  of  carbolized  or  other  anti- 
septic solutions  into  the  abscess  cavity 
and  the  use  of  drainage-tubes  will 
contribute  to  the  successful  treatment  of  such  cases.  There  are  now  on 
record  numerous  instances  of  trephining  and  brain  puncture  for  extrava- 
sated  blood,  cerebral  abscess  and  for  the  removal  of  brain  tumors,  which 
have  been  followed  by  recover3^ 


Cyrtometer  applied,  showing  G,  gla- 
bella, R,  junction  of  line  of  Rolandie  fis- 
sure with  median  line  from  glabella  to 
inion.     (Park.) 


Injuries  of  the  Brain. 


Under  this  heading  I  shall  discuss  wounds,  concussion,  and  compression 
of  the  brain,  leaving  fractures  of  the  skull  to  be  treated  in  the  chapter 
on  Diseases  and  Injuries  of  Bone. 

Scalp  AVounds. — It  is  usual  for  writers  to  devote  a  section  or  two  in 
this  connection  to  descriptions  of  scalp  wounds.  The  proximity  of  the 
brain  to  the  part  wounded  and  the  possibility  cf  the  vulnerating  force 
having  fractured  the  skull  or  caused  brain  injury  at  the  time  the  scalp 
wound  was  inflicted  should  make  the  surgeon  cautious  in  watching  symp- 
toms and  careful  in  the  treatment  of  scalp  wounds ;  but  there  is  nothing 
intrinsically  special  in  such  injuries.  They  should  be  rendered  aseptic 
and  be  approximated  by  sutures,  and  their  complications,  such  as  hemor- 
rhage, abscess,  and  erysipelas  met  as  in  ordinary  wounds.  The  pin  suture 
is  a  favorite  of  mine  as  it  controls  the  bleeding,  which  is  apt  to  be  profuse 
because  of  the  great  vascularity  of  the  scalp.     It  is  easy,  however,  to  con- 


192       DISEASES    AND    INJURIES    OF    NERVOUS    CENTRES. 

trol  heinorrha«j^e  by  a  tight  bandage  around  the  head,  for  the  cranium 
gives  a  firm  surface  against  which  to  make  pressure. 

Wounds  of  tiik  Bkaix. — Wounds  of  the  brain  are  usually  accom- 
panied by  fracture  of  the  skull.  Such  is  not  the  case,  however,  when 
laceration  from  sudden  jarring  occurs,  or  when  punctures  are  received 
through  the  fontanelles  or  other  openings  in  or  between  the  bones. 
Wounds  of  the  anterior  and  su})erior  region  are  less  serious  than  those  of 
the  base  or  posterior  part  of  theencephalon.  Very  serious  wounds  result 
when  fragments  of  a  fractured  cranial  bone  are  driven  into  the  meninges 
and  brain  substance.     Gunshot  wounds  are  also  very  destructive. 

The  symptoms  of  brain  wounds  depend  upon  the  situation  of  the  injury 
and  the  amount  of  nervous  tissue  involved,  as  is  easily  understood  from 
the  foregoing  remarks  on  cerebral  localization.  Shock,  paralysis,  and 
perhaps  unconsciousness,  in  varying  degrees,  are  the  early  symptoms  of 
brain  wounds,  and  are  soon  followed  by  local  or  general  inflammation  of 
the  brain.  Portions  of  brain  material  may  be  cut  off  by  the  surgeon  or 
carried  away  by  extensive  injury  and  recovery  be  not  only  possible  but 
even  probable  if  the  parts  are  kept  or  soon  rendered  aseptic. 

Treatment. — The  treatment  of  brain  wounds  is  embodied  in  two  pre- 
cepts :  Remove  the  foreign  body,  if  any  exists  and  it  can  be  withdrawn 
without  inflicting  grave  additional  injury;  and  prevent,  or  at  least  limit, 
the  secondary  inflammation  that  is  liable  to  follow  the  wound,  by  antisepsis 
and  most  thorough  drainage. 

Probing  brain  wounds  to  discover  the  locality  of  a  bullet  or  any  missile 
should  be  done  only  with  great  care  and  with  aseptic  precautions.  A  large- 
headed  probe  of  aluminium  is  the  best  instrument  and  should  be  allowed 
to  follow  the  bullet-track  by  its  own  weight  when  the  patient's  head  is  so 
placed  that  gravity  will  carry  the  probe  in  the  course  of  the  wound. 
Trephining  to  give  access  to  the  foreign  body  is  proper,  and  thorough 
drainage  by  means  of  rubber  tubes  is  essential  to  cure.  ^Nleasui-es  calcu- 
lated to  combat  encephalitis  should  be  employed.  Secondary  abscess 
must  be  diagnosticated  and  treated  as  described  in  the  section  on  cerebral 
inflammation.  Recent  observation  has  shown  that  the  brain  can  be 
punctured,  incised  and  excised  with  a  great  degree  of  impunity,  provided 
the  internal  ganglia  are  undisturbed  and  these  operations  are  rigidly 
aseptic. 

It  occasionally  happens  that  through  the  opening  in  the  membranes  and 
skull  there  occurs  during  the  progress  of  inflammation  a  fungoid  protru- 
sion of  brain  matter  mingled  with  lymph,  pus  and  blood.  This  consti- 
tutes the  condition  called  hernia,  or  fungus,  of  the  brain,  which  is  liable  to 
continue  until  either  exhaustion  or  the  damage  done  the  nervous  centres 
by  inflammation  causes  a  fatal  issue. 

Fungus  of  the  brain  demands  no  special  line  of  treatment;  but  clean- 
liness in  removing  the  discharges  and  the  use  of  antiseptic  dressings  are 
proper.  Moderate  pressure  upon  the  mass  may  be  attempted,  but  it  is 
liable  to  do  harm  by  causing  retention  of  the  secretions  within  the  cranial 
cavity.     To  cut  oft'  the  protuberance  is  not  infrequently  good  surgery. 

The  possibility  of  fungus  of  the  brain  occurring  must  be  remembered 
when  operations  are  performed  which  are  liable  to  divide  the  dura  mater; 
hence,  the  dura  mater  should  be  carefully  sutured  after  the  removal  of 
tumors  of  the  brain.  It  is  understood  that  provision  for  drainage  must 
be  made  through  the  dural  incisions,  by  tubes,  or  strands  of  catgut  or 
horsehair. 


CONCUSSION    OF    THE    BRAIN.  193 


Coxcussiox,  Contusion,  and  Laceration  of  the  Brain. 

Definition. — The  term  concussion  has  long  been  used  to  designate  the 
symptoms  which  follow  vibration  of  the  brain  consequent  upon  blows 
received  directly  upon  the  skull  or  transmitted  there  through  the  spinal 
column.  It  ^vas  supposed  that  a  man  might  die  instantly  from  concussion 
of  the  brain,  without  receiving  any  physical  lesion  of  the  brain  substance. 

Patholoc4Y. — This  assumption  I  believe  to  be  false,  for  fatal  cases  of 
so  called  concussion  of  the  brain  exhibit,  on  careful  examination,  con- 
tusion or  laceration  of  the  brain,  separation  of  the  dura  mater  from  the 
bones,  compression  from  clot,  or  some  distinct  lesion  of  the  contents  of  the 
cranium.  Death  in  cases  in  which  no  such  evidence  of  brain  injury  has 
been  found,  has  not  infrequently  been  attributed  to  concussion  of  the 
brain,  without  an  investigation  of  the  spinal  cord  and  heart.  Fatal 
changes  would  probably  have  been  found  there.  I  admit  the  jJossibility 
of  the  vibration  causing  a  molecular  change  in  the  nervous  cells,  the 
capillaries,  or  the  cerebro-spinal  .fluid,  which  could  not  be  appreciated  by 
our  ordinary  methods  of  investigation,  and  which  still  might  be  capable 
of  producing  the  symptoms  found  in  slight  concussion  ;  but  when  death 
occurs  in  cases  denominated  concussion  of  the  brain,  I  believe  that  dis- 
tinct lesions,  if  carefully  sought  for,  will  always  be  found. 

If  a  vessel  containing  jelly,  of  the  consistence  of  the  brain  and  contain- 
ing similar  cavities,  was  forcibly  struck,  fissures  could  easily  be  produced 
in  the  mass  by  irregular  transmission  of  the  vibrations  of  force.  So,  I 
believe,  do  lacerations  and  contusions  of  the  non-homogeneous  brain 
occur. 

In  my  opinion,  then,  concussion  of  the  brain  is  not  a  functional  condi- 
tion, but  is  used  to  designate  organic  changes.  The  term,  therefore, 
should  be  discarded  for  contusion  or  laceration. 

Cases  of  slight  concussion  very  much  resemble  a  similar  degree  of  that 
obscure  condition  called  shock.  It  is,  perhaps,  possible  that  a  sudden 
moderate  force  applied  to  the  head,  containing  cerebro-spinal  and  sympa- 
thetic nerve  centres,  causes  pallor,  vertigo,  and  confusion  of  ideas  by  the 
same  pathological  change  that  occurs  when  peripheral  nerves  are  injured. 

When  greater  violence  is  offered  to  the  brain  it  is  to  be  expected  that, 
in  addition  to  the  condition  of  shock,  symptoms  will  be  presented  due  to 
the  laceration  which  necessarily  occurs  because  of  the  jelly-like  consist- 
ence of  the  brain.  This  view  is  partially  substantiated  by  the  statement 
of  some  surgeons  that,  in  all  instances  of  concussion  severe  enough  to  cause 
unconsciousness,  serious  symptoms  are  liable  to  ensue.  This  theory  would 
place  under  the  head  of  shock  those  temporary  symptoms  now  called 
slight  concussion,  and  would  class  all  other  instances  of  brain  injury  of 
a  similar  character  as  contusion  or  laceration  of  the  brain. 

Lacerations  and  contusions  of  the  brain  may  be  multiple,  giving  rise  to 
numerous  minute  extravasations  of  blood,  scattered  throughout  the  brain 
and  scarcely  distinguishable  from  the  normal  vascular  points  seen  on 
section.  On  the  other  hand,  hemorrhage  from  the  torn  vessels  may  be  so 
great  and  so  diffused  as  to  produce  symptoms  of  compression  of  the  brain, 
thus  greatly  obscuring  the  diagnosis.  The  irregularity  of  the  base  of  the 
skull  causes  laceration  to  occur  most  frequently  in  the  corresponding  region 
of  the  encephalon. 

Causes. — Direct  violence  to  the  head,  or  force  applied  to  the  legs  or 
buttocks  and  transmitted  through  the  spinal  column  to  the  cranial  bones, 

13 


194      DISEASES    AND    INJURIES    OF    NERVOUS    CENTRES. 

are  the  causes  of  contusions  and  laceration  of  tiie  brain.  A  l)lo\v  on  one  part 
of  the  cranium  will  often  give  rise  to  laceration  of  the  i)rain  at  the  oppo- 
site side  without  there  being  any  marked  injury  to  the  cerebral  tissue  im- 
mediately underlying  the  bone  struck.  This  is  due  to  the  soft  consistency 
of  the  brain,  and  is  termed  contusion  by  counter-stroke. 

Symptom.s. — When  a  slight  blow  has  been  received  by  the  brain  the 
patient  at  once  becomes  giddy,  is  confused  in  his  ideas,  feels  weak,  staggers 
and  perhaps  would  fall  if  not  steadied  by  grasping  souie  neighboring  sup- 
port. At  the  same  time  his  face  becomes  pallid,  and  his  heart's  action 
feeble.  There  is  a  feeling  of  nausea,  and  vomiting  sometimes  actually 
occurs.  These  slight  cases  do  not  exhibit  actual  unconsciousness,  but  the 
patient  is  "  stunned,"  and  for  a  moment  is  not  able  to  collect  his  thoughts. 
He  in  a  moment  jiromptly  returns  to  his  normal  state. 

This  is  the  condition  in  which  it  is  possible,  perhaps,  that  no  laceration 
of  nervous  structure  or  bloodvessel  occurs;  and  such  cases  are  those  that 
resemble  surgical  shock  of  slight  severity. 

The  violent  shaking  of  the  l)rain  caused  liy  the  application  of  a  severe 
force  is  followed  by  symptoms  of  gravity,  which  are  due,  in  my  opinion, 
to  the  production  of  contusion  or  laceration  of  the  brain  or  its  membranes. 
The  patient  is  almost,  but,  as  a  rule,  not  completely,  unconscious  ;  lies 
motionless  with  a  cold,  pallid  skin,  has  a  feeble,  fluttering  pulse  and 
heart,  and  sometimes  passes  urine  and  feces  involuntarily.  The  insensi- 
bility is  not  a  complete  coma,  for  usually  the  patient  can  be  roused  by 
loud  questioning  to  utter  a  monosyllable  or  a  groan.  The  pupils  vary 
in  different  cases  as  to  contraction  or  dilatation,  and  the  two  eyes  may  not 
be  alike  in  this  respect.  Usually  the  pupils  react  to  the  stimulus  of  light. 
The  breathing  is  quiet,  though  it  may  be  feeble  and  shallow  ;  there  is  no 
hemiplegia,  and  the  limbs  if  pricked  with  a  pin  will  be  withdrawn,  though 
])robably  in  a  lazy  manner.  Vomiting  is  liable  to  occur  as  the  ])atient 
begins  to  react  from  the  semi-unconscious  condition  which  has  immediately 
succeeded  the  injury.  Convulsions  sometimes  take  place  after  such  cere- 
bral injuries.  The  location  of  the  contusion  is  an  iniportant  factor  in  the 
determination  of  special  symptoms.  The  synijitoms  just  described  may 
last  a  few  hours  or  a  day,  before  signs  of  recovery  or  of  j)rogressive  in- 
flammation supervene.  When  return  to  health  is  to  ensue,  the  symptoms 
of  brain  contusion  slowly  subside  and  the  patient's  functions  assume  their 
normal  condition.  It  often  happens,  however,  that  headache,  vertigo, 
impaired  memory,  and  other  cerebral  sequelie  remain.  When  the  issue 
of  the  injury  is  to  be  an  unfavarable  one,  the  patient  either  sinks  into  a 
comatose  state,  without  reacting,  or,  if  he  does  react,  soon  presents  the 
characteristic  symptoms  of  encephalitis. 

The  prognosis  is  grave  in  all  cases  of  contusion  of  the  brain,  because  it 
is  impossible  to  define  accurately  the  extent  of  the  lesion,  and  because 
even  slight  lacerations  and  contusions  are  liable  to  impair  the  mental 
functions  and  the  special  senses.  All  injuries  producing  vibration  or  con- 
cussion of  the  braiu  that  are  followed  by  the  semi -unconsciousness  men- 
tioned are  serious,  because  there  is  organic  lesion  of  the  braiu  tissue. 

Some  writers  speak  of  three  stages  of  concussion  of  the  brain — namely  : 
collapse,  reaction,  and  inflammation. 

I  object  to  this  division,  and,  indeed,  ignore  entirely  the  term  concussion 
of  the  brain,  since  I  do  not  believe  in  the  existence  of  a  functional  dis- 
turbance of  the  brain  without  organic  lesion.  Concussion  of  a  muscle  or 
bone  causes  a  definite  lesion  called  contusion,  laceration,  fracture ;  so 
concussion  of  the  brain,  if  it  produces  symptoms,  must  cause  an  organic 


COMPEESSION    OF    THE    BRAIN.  195 

lesion.  In  cases  subjected  to  careful  autopsy  such  lesions  are  found, 
though  it  is  possible  that  instances  may  occur  in  which  organic  change  is 
too  slight  to  be  appreciated  by  our  present  knowledge  and  means  of  in- 
vestigation. 

Concussion  or  vibration  of  the  brain  should  not  be  considered  a  condi- 
tion of  disease  of  the  brain,  but  merely  a  cause  of  contusion  and  lacera- 
tion of  the  organ.  Let  the  term  concussion,  as  usually  employed,  be 
dropped,  and  contusion  or  laceration  substituted,  and  such  symptoms  as 
those  I  have  been  describing  will  be  better  understood  and  better  treated. 
The  three  stages  of  concussion,  called  the  stage  of  collapse,  that  of  reaction, 
and  that  of  inflammation,  are  relics  of  the  old  nomenclature,  and  are  un- 
necessary. If  concussion  is  synonymous  with  contusion  or  laceration,  as 
it  should  be,  the  occurrence  of  reactionary  and  inflammatory  phenomena 
is  readily  intelligible. 

Treatment. — As  the  symptoms  are  those  of  shock,  combined  with 
those  of  brain  contusion  and  laceration,  the  treatment  is  obviously  clear. 
At  fii'st  absolute  quiet  in  the  supine  position,  with  the  feet  elevated  slightly 
and  the  head  low,  should  be  enjoined.  A  darkened  room  and  an  oppor- 
tunity to  sleep  should  be  afforded.  Stimulants  will  rarely  be  needed,  and 
should  be  avoided  if  possible;  because,  after  the  shock  of  injury  has 
passed  away,  cerebral  excitation  and  plethora  will  tend  to  produce  hem- 
orrhage from  the  torn  vessels,  and  to  set  up  inflammatory  engorgement. 
Agents,  such  as  ammonia,  that  stimulate  momentarily,  are  preferable  to 
the  more  lasting  alcoholic  preparations.  External  applications  of  heat 
or  of  mustard  to  the  general  surface  may  be  available  to  relieve  the 
depression.  When  the  pulse  shows  increasing  strength,  or  there  is  evi- 
dence in  the  reddening  of  the  skin  that  reaction  has  commenced,  the  sur- 
geon must  adopt  measures  to  prevent  the  occurrence  of  cerebral  inflamma- 
tion. The  head  should  be  elevated,  cold  applied  locally,  and  bromide  of 
potassium,  purgatives,  and  other  remedies  employed  in  the  manner  described 
when  speaking  of  inflammation  of  the  brain  from  surgical  causes.  Even 
bloodletting  may  be  required,  though  in  the  early  hours  after  the  injury 
such  treatment  might  prove  fatal.  It  requires  the  exercise  of  great  judg- 
ment to  manage  such  cases.  The  measures  appropriate  for  the  first  few 
hours'  treatment  of  contusion  of  the  brain  are  diametrically  opposed  to 
the  line  of  treatment  required  after  reaction  has  been  induced.  It  is  a 
nice  question  to  know  when  the  change  should  be  made. 

All  cases  of  contusion  of  the  brain,  however  slight,  require  surgical 
supervision  for  a  long  time.  Indiscretions  in  mental  work,  in  diet,  or  in 
physical  exercise  may  be  very  deleterious. 

Compression  of  the  Brain. 

Definition. — Compression  of  the  brain  is  said  to  exist  when  pathologi- 
cal lesions  or  changes  exert  such  pressui'e  upon  the  organ  as  to  displace 
the  cerebral  substance  or  cause  flattening.  The  symptoms  are  probably 
due,  to  a  great  extent  at  least,  to  the  pressure  impeding  cerebral  circula- 
tion and  causing  a  local  deficiency  of  blood  supply.  It  is  certainly  not 
likely  that  the  amount  of  force  exerted  by  extravasated  blood,  which  so 
often  gives  rise  to  compression  symptoms,  is  sufficient  actually  to  compress 
and  condense  the  brain  substance.  It  would  require  comparatively  little 
pressure,  however,  to  interfere  with  the  calibre  of  the  capillary  blood- 
vessels. 


196      DISEASES    AND    INJURIES    OF    NERVOUS    CENTRES. 

Causes. — The  causes  ot  compression  of  the  l)raiii  are:  1.  Extravasa- 
tion of  blood  upon  the  surface  or  in  the  interior  of  tiie  brain.  2.  Fractures 
of  the  skull,  acconijianied  by  depression  of  the  fragments,  o.  Foreij^n 
bodies  driven  throujrh  the  skull  upon  the  surface  of  or  into  the  brain. 
4.  Inriammatorv  deposits  of  serum,  lymph,  or  pus.  In  the  second  and 
third  instances  bleeding,  due  to  laceration  accompanying  the  fracture  or 
wound,  has  frequently  much  to  do  with  the  occurrence  of  compression. 
A  comparatively  sudden  j)ressure  seems  to  be  requisite  to  produce  com- 
pression symptoms.  If  blood,  for  example,  be  slowly  extravasated,  the 
brain  seems  to  accommodate  itself  to  its  new  relations,  unless  the  amount 
of  blood  be  great. 

Symptoms. — A  patient  suffering  with  compression  of  the  brain  is  dead 
to  external  impressions,  but  the  organic  functions  of  respiration  and  circu- 
lation continue.  He  lies  on  his  back,  totally  unconscious  and  immovable, 
with  pupils  unaffected  by  light,  and  one  or  both  of  them  usually  moder- 
atelv  or  considerably  dilated.  The  respiration  is  slow  (ten  to  sixteen  per 
minute),  snoring,  and  accompanied  by  a  peculiar  whiff  or  puffing  out  of 
the  cheek  at  the  corner  of  the  mouth.  The  stertor  is  due  to  paralysis  ot 
the  palate  muscles.  It  may  be  greatly  diminished  by  turning  the  patient 
on  his  side,  so  that  the  relaxed  soft  palate  will  not  hang  unsupported  in 
the  current  of  air.  The  puffing  out  of  the  cheek  is  due  to  loss  of  })ower 
in  the  buccal  muscles.  The  pulse  is  slow  and  rather  full,  beating  perhaps 
not  more  than  forty  or  fifty  times  in  a  minute.  The  urine  is  retained 
until  the  paralyzed  bladder  becomes  so  distended  that  there  is  a  dribbling 
overflow.  Constipation,  followed  by  relaxation  of  the  anal  sphincter  and 
consequent  incontinence  of  feces,  is  often  found.  Hemiplegia  of  the  side 
opposite  the  injury  is  usual.  This  cannot  be  determined  in  cases  where 
reflex  sensibility  is  destroyed,  unless  it  is  evident  from  the  distortion  of  the 
face.  The  condition  of  the  pupils  and  the  extent  and  character  of  the 
paralysis  depend  upon  the  situation  of  the  compressing  lesion.  The  group 
of  svmptoms  given  are  those  found  in  typical  cases  of  compression,  and  are 
those  of  cerebral  apoplexy,  which  is  a  form  of  compression. 

Symptoms  of  comjjression  due  to  depressed  bone  or  to  foreign  bodies 
lodged  in  the  brain  arise  immediately  after  the  receipt  of  injury.  Extrav- 
asation of  blood,  unless  profuse,  causes  a  gradual  supervention  of  symp- 
toms, while  compression  from  infiammatory  products  apj)ears  only  at  a 
later  period.  It  is  probable  that  a  factor  in  many  cases  of  compression 
from  depressed  fracture  is  the  concomitant  occurrence  of  inflammation, 
whose  symptoms  are  blended  with  those  due  to  the  pressure  which  often  is 
too  slight  to  cause  in  itself  serious  symptoms. 

If  the  pressure  is  not  relieved  by  treatment,  and  the  cerebral  mass  fails 
to  accommodate  it.self  to  the  new  relation  of  parts,  coma  deepens,  the 
organic  functions  become  gradually  involved  and  death  occurs.  The  time 
occupied  in  the  fatal  invasion  and  destruction  of  these  functions  is  usually 
a  few  days,  though  it  may  extend  through  weeks. 

Diagnosis. — Typical  cases  of  compression  of  the  brain  are  readily  dis- 
tinguished from  contusion  or  laceration  (so-called  concussion)  of  the  brain 
of  moderate  severity.  If  a  laceration  or  contusion  is  sufficient  to  cause 
much  hemorrhage,  however,  compression  symptoms  will  coexist  and  com- 
plicate the  diagnosis.  So,  on  the  other  hand,  laceration  and  contusion  of 
the  brain  substance  is  liable  to  result  from  the  same  force  that  ])roduces  a 
depressed  fracture  and  a  consequent  depression.  Hence,  it  is  often  impos- 
sible to  determine  accurately  the  pathological  lesion. 


COMPEESSIOX    OF    THE    BRAIN.  197 

The  points  upon  which  a  differential  diagnosis  may  be  founded  in  uncom- 
plicated cases  are  given  in  the  following  table  : 

r,  •  Contudoii  or  Laceration 

-^  ( Concussion). 

1.  Symptoms   may   not    be   immediate         Symptoms  always  immediate. 

after  injury. 

2.  Complete   unconsciousness   and  totai         Partial  unconsciousness  and  only  impaired 

insensibility   to   imi^ressions   upon  sensibility  to  impressions  upon  organs  of 

organs  of  sense.  sense. 

3.  Eespiration  slow,  stertorous,  and  putF-         Respiration  quiet. 

iug. 

4.  Pulse  slow  and  full.  Pulse  frequent  and  feeble. 
.5.  Xo  vomiting.                                                    Sometimes  vomiting. 

6.  Ptetention  of  ui'iue  and  often  of  feces.         Incontinence  of  urine  and  feces. 

7.  Paralysis,  usually  hemiplegia,  of  op-         'Ko  paralysis. 

posite  side. 

8.  Pupils  insensible  to  ligbt.  Pupils  react  somewhat  to  light. 

9.  Deglutition  imijossible.  Deglutition  possible. 

In  the  absence  of  a  history  oi  the  patient  before  unconsciousness 
occurred,  it  is  frequently  difficult  and  sometimes  impossible  to  discriminate 
between  coma  due  to  compression  of  the  brain,  alcoholic  or  narcotic 
poisoning,  uremia,  apoplexy,  sunstroke,  and  hysteria.  An  unconscious 
man  with  bruises  upon  the  head,  picked  up  in  the  streets,  may  be  suffer- 
ing from  brain  compression  due  to  injuries  received  while  intoxicated ; 
or  may  haye  fallen  from  au  elevation  because  of  an  apopletic  seizure  or 
sunstroke,  and  thus  have  sustained  secondarily  a  depressed  fracture  of  the 
skull.  In  such  cases  the  head  should  be  shaved,  and  careful  examination 
made  for  signs  of  injury  to  the  skull ;  the  urine  should  be  examined  for 
albumin  and  tube  casts,  alcohol,  opium,  and  other  poisons ;  the  tempera- 
ture should  be  taken,  and  tests  of  electro-muscular  sensibility  and  con- 
tractility should  be  instituted. 

The  ophthalmoscope  will  sometimes  be  of  service  in  disclosing  albu- 
minuric retinitis  and  choked  disk,  or  other  changes  in  the  fundus. 

The  existence  of  paralysis  in  compression  of  the  brain  usually  serves  to 
distinguish  it  from  the  conditions  named,  with  the  exception  of  apoplexy. 
It  is  the  compression  produced  by  the  hemorrhage  in  an  apoplectic  seizure 
that  induces  many  of  the  symptoms  ;  hence,  a  diagnosis  is  impossible 
unless  the  history  and  evidences  of  injury  afford  direct  information.  The 
treatment,  however,  is  identical  in  such  conditions. 

The  odor  of  poisons,  the  contracted  pupils  of  opium  narcosis,  the  oedema 
of  chronic  Bright's  disease,  the  high  temperature  of  sunstroke,  and  the 
sex  in  hysteria  will  aid  in  the  differentiation  of  some  obscure  cases.  Such 
evidence  is  fallible,  however,  and  it  may  be  that  the  surgeon's  opinion 
must  be  suspended  until  the  progress  of  the  case  clears  up  the  obscurity. 
The  patient  may  indeed  be  suffering  from  two  conditions  at  the  same 
time. 

Treatment. — Compression  of  the  brain  demands  removal  of  the  cause 
if  this  can  be  done  without  inflicting  more  serious  brain  injury.  Depressed 
bone  should  be  elevated  ;  foreign  bodies  extracted ;  pus  evacuated  by 
trephining  ;  extravasated  blood  removed  and  further  bleeding  prevented 
by  opening  the  skull,  turning  out  the  clots,  and  tying  the  vessel.  These 
operative  procedures  are  proper  only  when  the  existence  of  compression 
is  clearly  established,  and  its  cause  and  location  known.  Investigations 
of  the  localization  of  cerebral  lesions  and  improved  methods  of  treating 


198      DISEASES    AXl)    INJURIES    OF    NERVOUS    CENTRES. 

wounds  have  made  such  operations  more  fre(iuently  justifial)le  than  was 
formerly  tlie  case.  When  such  measures  are  not  deemed  wise,  the  patient 
shouUl  l)e  treated  on  the  general  principles  laid  down  for  the  prevention 
of  encephalitis. 

Purgatives,  bromide  of  potassium,  iodine  and  its  compounds,  mercury, 
and  bloodletting  are  the  remedies  to  be  employed.  If  hemorrhage  is 
supposed  to  be  the  cause  of  compression,  the  head  should  be  elevated. 
Enemas  may  be  given  to  empty  the  lower  bowel.  The  catheter  must  be 
introduced  twice  or  thrice  daily  to  withdraw  the  urine  from  the  paralyzed 
bladder. 

Tumors  of  thk  Brain. 

Tumors  of  the  brain  may  be  fibromas,  sarcomas,  carcinomas,  cystic 
tumors,  etc.  They  may  have  their  seat  between  the  dura  and  the  cerebral 
convolutions,  or  they  may  be  more  or  less  deeply  imbedded  within  the 
brain  tissue.  The  symptoms  depend  upon  the  position  of  the  growth  and 
its  size.  Epileptic  convulsions,  local  paralyses  and  spasms,  choked  disks, 
aphasia,  and  intellectual  aberrations  all  occur.  It  is  the  simultaneous  or 
consecutive  occurrence  of  these  and  other  symptoms  which  enables  the 
neurologist  to  localize  the  position  of  the  growth.  If  such  a  tumor  does 
not  involve  the  basal  ganglia,  nor  occupy  a  position  so  far  under  the  base 
of  the  brain  as  to  make  access  impossible,  it  is  proper  to  attempt  its  re- 
moval by  opening  the  skull  and  excising  it.  Such  operations  should  be 
done  with  the  strictest  antiseptic  precautions  and  by  means  of  a  large 
trephine  and  gnawing  forceps.  Provision  must  be  made  for  drainage, 
even  if  the  opened  dura  mater  is  subse<iuently  sutured,  as  it  usually 
should  be,  and  if  the  button  of  bone  cut  out  by  the  trephine  is  replaced 
before  the  scalp  Hap  is  sutured  into  position.  The  details  of  such  opera- 
tions will  be  found  in  the  various  monographs  which  have  recently  been 
written  on  this  subject. 

Growths  situated  at  some  distance  below  the  surface  of  the  convolu- 
tions are  not  accessible  until  the  surgeon  has  incised  the  brain  tissue. 
This  procedure  is  justifiable,  if  punctures  carefully  made  with  a  probe  or 
grooved  director  give  evidence  of  a  tumor  below  the  surface.  When  the 
clinical  history  of  the  patient  shows  evidence  of  multiple  brain  tumors  or 
of  a  tumor  which  is  evidently  a  secondary  malignant  growth,  it  is  scarcely 
proper  to  attempt  removal.  The  diagnosis  in  cases  of  suspected  brain 
tumor  is  very  difficult  and  reijuires  the  most  careful  consideration  of  the 
skilled  neurologist.  It  is  probably  true  that  surgeons  usually  have  not 
the  special  knowledge  which  enables  them  to  make  an  absolute  diagnosis 
as  to  location.  Hence,  examination  of  the  eye  grounds,  of  the  paralytic 
symptoms,  and  of  the  epileptiform  seizures  should  be  made  by  those  who 
are  trained  to  such  matters.  When  a  reasonable  diagnosis  has  been  made 
by  such  expert  observation,  it  is  proper  to  perform  an  exploratory  opera- 
tion. 

Diseases  and  In.juries  of  the  Spinal  Cord. 

Hydrorachis  or  Bifid  Spine. 

Hydrorachis  is  a  congenital  protrusion  of  the  membranes  ot  the  spinal 
cord  and  sometimes  of  a  portion  of  the  cord  itself  or  of  the  spinal  nerves 
through  an  opening  in  the  posterior  part  of  the  vertebral  column.     The 


DISEASES    AND    INJURIES    OF    THE    SPINAL    CORD. 


199 


deficiency  of  the  bony  wall  is  due  to  imperfect  development  of  the 
laminae  and  spinous  process  of  one  or  more  vertebrae ;  hence,  the  name  of 
bifid  spine.  The  protruded  membranes  are  distended  by  cerebral  spinal 
fluid  forming  an  elastic  and  sometimes  fluctuating  tumor.  A  more  proper 
name  would  be  spinal  meningocele.  Those  protrusions  containing  por- 
tions of  the  cord  would  then  be  called  myeloceles.  The  deformity  occurs 
most  frequently  in  the  lumbo-sacral  region. 


Fi&.  80. 


^S(    Inside  of  sac 
luit/t  neiueb 


Dissection  of  hydrorachis.     (Bryant.) 


The  tumor  varies  in  size  and  in  tenseness  with  the  position  of  the  child, 
and  in  occasional  instances  has  no  cutaneous  investment  whatever,  being 
a  mere  sac  of  thin  spinal  membranes.  It  is  apt  to  become  more  tense  or 
larger  when  the  child  cries.  The  fluid  can  sometimes  be  pressed  back 
into  the  spinal  canal  so  that  the  edges  of  the  fissure  in  the  bones  can  be 
distinctly  felt.  Hydrocephalus  and  other  deformities  are  often  found  in 
the  same  infant.  Paralysis  is  not  uncommon.  Death  generally  occurs 
from  meningitis,  convulsions,  or  paralysis,  or  from  rupture  or  ulcei'ation 
of  the  sac. 

Support  and  moderate  pressure  by  means  of  elastic  bandages  or  cup- 
shaped  pads  afford  proper  palliative  treatment.  When  the  growth  is 
rapidly  increasing  a  portion  of  the  fluid  may  be  withdrawn  by  an  aspira- 
tion-needle, introduced  at  the  side  of  the  median  line  where  nerves  are 
not  likely  to  be  situated.  If  the  orifice  of  communication  with  the  spinal 
canal  is  small,  injections  of  tincture  of  iodine,  ligation  with  the  elastic 
ligature,  or  excision  may  be  practised.  All  tumors  over  the  spine^  in 
children  are  not  cases  of  bifid  spine ;  but  the  possibility  of  this  condition 


200      DISEASES    AND    INJURIES    OF    NERVOUS    CENTRES. 

existing   should  always  be  in    the  surgeon's    mind  before   undertaking 
operation. 

Ikflammatiox  of  the  Spinal  Cord  from  Surgical  Causes. 

Varieties. — The  inHaraniatory  process  may  be  located  in  the  meni- 
liranes  (spinal  meningitis),  or  in  the  substance  of  the  cord  (myelitis).  It 
frequently  happens  that  meningitis  and  myelitis  are  associated. 

Patholociy. — In  traumatic  cases  the  inflammation  is  usually  local,  but 
the  pathological  changes  may  gradually  spread  along  the  spinal  marrow. 
Injection  of  vessels,  effusion  of  serum,  exudaticm  of  lymph,  formati(m  of 
]nis,  and  softening  of  nervous  structure  are  the  results  found  at  the  after- 
death  examination.     Sclerosis  may  occur  in  chronic  cases. 

Causes. — Intraspinal  inflammations  of  surgical  causation  arise  from 
contusions  or  lacerations,  and  other  direct  wounds  of  the  contents  of  the 
vertebral  canal ;  and  from  fracture,  caries,  and  necrosis  of  the  vertebrai. 

Symptoms. — There  are  certain  differences  in  the  symptomatology  of 
meningitis  and  myelitis  which  will  be  discussed  in  speaking  of  diagnosis. 
Here  the  symptoms  of  spinal  inffammation  in  general  will  be  described. 

As  the  cause  is  local  the  inflammation  is  limited  ;  hence,  chills,  high 
fever,  and  great  constitutional  disturbance  are  unusual.  Pain  in  the 
spinal  region,  aggravated  by  motion  or  pressure,  and  often  reflected  along 
the  nerve  trunks,  is  exhibited.  Burning  and  tingling  sensations  and  a 
feeling  of  insects  creeping  over  the  body ;  local  hyperiosthesia  of  the 
surface ;  more  frequently  cutaneous  ana'Sthesia  :  delay  in  perceiving  the 
contact  of  points  ;  and  a  sense  of  constriction  about  the  body  marking  the 
upper  limit  of  the  disease  are  common  symptoms  of  inflammation  of  the 
cord  and  its  coverings. 

Muscular  jerking-s  and  spasms,  and  subsequently  permanent  muscular 
contractions,  affecting  the  muscles  supplied  from  the  diseased  region,  are 
especially  associated  with  meningitis.  iNIotor  paralysis  ])elow  the  seat  of 
lesion  is  usually  present,  being  much  more  permanent  and  complete  in 
myelitis. 

The  palsy,  as  a  rule,  involves  both  sides,  and  is  due  to  division,  com- 
pression, or  disorganization  of  the  nerve  fibres  of  the  cord.  If  paraplegia 
occurs  immediately  after  the  receipt  of  injury,  it  indicates  that  the  fibres 
are  divided,  or  have  been  compressed  by  displaced  bone  or  extravasated 
blood.  A  slowly  determined  paralysis  suggests  inflammatory  pressure  or 
disorganization.  Injury  of  one  side  of  the  si)inal  marrow  would  give  rise 
to  unilateral  palsy  on  the  same  side.  It  is  possible  in  lesions  of  the  cervico- 
dorsal  area  of  the  cord  to  have  motor  paralysis  of  the  arms  and  not  of 
the  legs.  As  the  cord  terminates  at  the  level  of  the  second  lumbar  ver- 
tebra, injuries  below  this  point  are  accompanied  by  no  paralysis,  or  by  a 
slight  and  temporary  form  only  which  depends  upon  lesions  of  the  loose 
bundle  of  nerves  called  the  horsetail.  The  small  diameter  of  the  cord 
immediately  above  its  lower  end  and  the  envelopment  of  this  termination 
in  the  nerve  roots  going  down  the  vertebral  canal  serve  to  prevent  severe 
involvement  of  the  cord,  even  at  a  somewhat  higher  level  than  the  lumbar 
vertebra  mentioned. 

The  seat  of  the  cord  lesion  can  often  be  determined  by  the  limitation  ot 
the  motor  or  sensory  paralysis.  The  muscles  and  regions  supj^lied  by 
branches  given  off  from  the  spinal  marrow  below  the  injury  are  usually 
the  only  ones  that  lose  their  innervation.  On  account  of  the  downward 
distribution  of  the  nerves  as  they  leave  the  cord,  the  lesion  is  generally 


IXFLAMMATION    OF    THE    SPINAL    CORD.  201 

somewhat  higher  than  the  horizontal  line  marking  the  upper  limit  of  the 
palsy.  An  exception  to  this  may  occur  when  the  terminal  nerve  filaments 
are  distributed  upward.     This  occurs  especially  in  the  skin.^ 

The  paralyzed  parts  are  exceedingly  liable  to  severe  bedsores.  These 
are  due  to  the  impaired  innervation  and  circulation  and  to  the  unrecog- 
nized irritations  which  the  insensible  and  immovable  parts  receive.  The 
local  temperature  of  the  palsied  limbs  is  often  high.  Atrophy  soon  occurs. 
Bedsores  and  atrophic  changes  are  more  marked  the  longer  the  patient 
survives.  Hence,  in  injuries  low  down  in  the  cord  these  nutritional 
changes  are  exceedingly  conspicuous. 

Retention  of  urine  occurs  nearly  always.  "When  the  paralyzed  blad- 
der has  become  fully  distended,  there  is  a  dribbling  overflow,  which 
is  an  indication  for  an  immediate  catheterization,  lest  rupture  of  the 
bladder  or  other  harm  result.  After  a  few  days'  incontinence  of  urine 
relaxation  of  the  sphincter  supervenes.  The  bladder  is  thus  kept  nearly 
empty.  At  the  same  time  the  urine  exhibits  chemical  changes,  becoming 
alkaline,  turbid,  ammoniacal  and  filled  with  mucus  and  phosphates. 
Inflammation  of  the  bladder  is  usually  found  at  this  period,  due  either  to 
the  distention  and  catheterization,  or  the  alkaline  urine,  or  perhaps  to 
both.  Other  changes,  such  as  the  presence  of  sugar,  are  occasionally 
witnessed. 

Priapism,  either  spontaneously  exhibited  or  following  catheterization 
and  handling  of  the  genitals,  occurs  in  many  instances  where  motor  palsy 
is  a  symptom.  It  has  no  connection  with  sexual  feelings,  and  only  exists 
Avhen  loss  of  motion  is  present. 

Incontinence  of  feces  is  seen  when  the  sphincter  is  paralyzed  by  injury 
to  the  lowest  region  of  the  cord.  If  the  damage  is  efiected  higher  up, 
constipation  is  the  condition  exhibited.  This  may  subsequently  be 
followed  by  looseness  of  the  bowels. 

Dyspnoea  and  hurried  respiration  result  when  the  spinal  inflammation 
is  located  in  the  upper  dorsal  and  cervical  regions  because  of  paralysis  of 
the  intercostal  and  serrated  muscles.  If  the  injury  disorganizes  the  cord 
above  the  origin  of  the  phrenic  nerve,  or  if  inflammatory  destruction 
ascends  thus  far  (to  the  third  or  fourth  cervical  vertebra),  death  occurs 
instantly  from  paralysis  of  the  diaphragm.  Difficulty  of  respiration  is 
experienced  in  intraspinal  troubles  in  the  lower  dorsal  region ;  first, 
because  there  is  paralysis  of  the  abdominal  muscles  which  aid  expiration, 
and  also  because  the  loss  of  muscular  tonicity  here  allows  tympanitic  dis- 
tention of  the  intestines  to  occur  and  interfere  with  the  descent  of  the 
diaphragm. 

When  the  sympathetic  cardiac  nerves  are  interfered  with  by  lesions  in 
the  cervico-dorsal  region,  the  pneumogastric  nerve  can  then  exert  its  in- 
hibitory function  unrestrained,  and  the  heart's  action  is  slowed.  Other- 
wise the  pulse  is  influenced  merely  by  the  general  state  of  the  patient. 

There  are  many  other  symptoms  of  intraspinal  inflammation  which 
depend  upon  the  location  of  the  lesion  and  the  nervous  centre  consequently 
involved.  From  these  the  location  of  spinal  lesions  is  established  with 
considerable  certainty.  It  must  be  remembered,  however,  that  in  some' 
cases  brain  injury  has  been  associated  with  the  spinal  hurt.  It  is  occa- 
sionally difficult  to  diflTerentiate  the  spinal  Irom  the  cerebral  symptoms. 

1  See  Spinal  Localization  in  its  Practical  Pi,elations.  Therapeutic  Gazette,  May  and 
June,  1889,  by  Dr.  Charles  K.  Mills. 


202       DISEASES    AND    INJURIES    OF    NERVOUS    CENTRES. 

Unconscioiisne.ss,  wlien  present,  renilers  the  diagnosis  of  cerebral  involve- 
ment clear. 

DiAcNOsis. — Menintritis  and  jnyelitis  are  often  combined,  but  the  pre- 
dominant atiection  can,  at  times,  be  diagnosticated  by  the  character  of  the 
symptoms.  In  meningitis  there  is  more  pain  on  motion,  more  cutaneous 
hypenesthesia,  more  tAvitching  and  permanent  contraction  of  muscles,  less 
impairment  of  motility,  less  involvement  of  the  bladder  and  rectum.  Effu- 
sion occurring  in  meningitis  may  cause  paraplegia  by  pressure  on  the  cord, 
but  the  paralysis  is  not  as  complete  as  in  myelitis,  and  varies  iu  its  degree. 

In  myelitis  the  loss  of  power  occurs  earlier  and  is  more  marked,  electric 
contractility  and  reflex  movements  are  soon  impaired,  and  the  sense  of 
constriction  about  the  trunk  is  conspicuous.  Priai)ism,  urinary  complica- 
tions, bedsores,  and  nutritive  changes  are  usual. 

Prognosis. — The  higher  the  seat  of  inflammation  the  graver  the  prog- 
nosis as  to  prolongation  of  life,  because  more  of  the  vital  functions  are 
impaired.  Myelitis  is  a  much  more  serious  aflection  than  meningitis,  and 
is  seldom  followed  by  restoration  of  the  paralyzed  limbs.  If  the  injury  is 
low  down  in  the  spine,  or  if,  when  higher,  it  implicates  a  limited  area  of 
the  cord,  recovery  of  a  fair  amount  of  health  occasionally  takes  place. 
Contractures  and  paralysis,  however,  usually  remain.  Sensation  is  usually 
regained  sooner  than  motion. 

Treatment. — Intraspinal  inflammation  recjuires  a  line  of  treatment 
similar  to  that  recommended  in  encephalitis.  Rest,  preferably  in  the 
prone  position,  the  ice-bag,  leeches  or  wet  cups  locally  ;  hydragogues, 
iodide  of  potassium  Cgr.  x  to  .^j),  or  mercury  to  slight  ptyalism,  and  fluid 
extract  of  ergot  (fj^ss  to  f^j),  given  internally  several  times  daily,  are  the 
proper  measures  in  acute  cases.  ]Morphia  and  bromide  of  potassium  may  be 
employed  to  relieve  pain  and  induce  functional  rest.  Atropia  is  an  appro- 
priate remedy  in  meningeal  congestion.  When  the  condition  is  subacute, 
blisters  or  the  actual  cautery  may  be  applied  to  the  spine  and  the  induced 
current  to  the  paralytic  muscles  with  advantage.  Hammond  says  that  in 
acute  partial  myelitis  he  has  got  benefit  from  large  doses  of  ergot,  and  the 
actual  cautery  applied  along  the  sides  of  the  spinous  processes.  Strychnia 
is  to  be  avoided  in  spinal  meningitis.  The  paralyzed  muscles  of  chronic 
myelitis  should  be  treated  by  means  of  electricity,  massage,  the  hot  and 
cold  douche,  and  subcutaneous  injections  of  strychnia,  in  the  endeavor  to 
prevent  atrophy  and  restore  power.  Syi)hilitic  meningitis  and  myelitis 
especially  call  for  mercury  and  iodide  of  potassium  in  active  doses. 

Suspension  by  the  shoulders  and  head  fx-om  a  tripod,  so  as  to  extend 
the  spinal  column  by  the  weight  of  the  lower  limbs,  has  been  advocated  in 
some  forms  of  chronic  disease  of  the  cord. 

When  retention  of  urine  exists,  the  catheter  must  be  passed  three  times 
daily.  The  cystitis  that  arises  later  and  is  accompanied  by  phosphatic 
urine,  is  alleviated  at  times  by  carefully  washing  out  the  bladder  with 
nitric  acid  and  water  (n^v  to  f^j).  Even  if  incontinence  has  occurred,  it 
is  well  to  i)ass  the  catheter  once  every  three  or  four  days  to  empty  any 
decomposing  residual  urine. 

An  attempt  at  preventing  bedsores  should  be  made  by  seeing  that  there 
are  no  folds  in  the  sheets,  by  bathing  the  prominent  points  of  back  and 
limbs  with  alcohol,  and  by  keeping  them  free  from  contact  with  the  urine 
and  feces.  It  is  well  to  place  the  patient  as  soon  as  possible  upon  an  air 
or  water  bed.  A  good  water  bed  can  be  improvised  by  partly  filling  a 
long  tank  or  tub  with  water,  and  nailing  a  rubber  blanket  over  the  top,  so 
that  it  will  rest  upon  the  surface  of  the  water. 


XEURITIS,    OR    INFLAMMATION    OF    NERVES.  203 

If  a  clear  diagnosis  of  abscess  within  the  spinal  canal  was  made,  it 
would  be  justifiable  to  trephine  the  vertebra,  or  to  saw  away  the  laminae 
in  an  efibrt  to  evacuate  the  pus.  In  localized  inflammation  due  to  frac- 
ture or  other  cause,  trephining  followed  by  separation  of  the  adherent 
membranes  and  cord  might  possibly  give  relief  to  the  symptoms.  Explo- 
ratory operations  here,  as  in  brain  diseases,  are  justifiable.^ 

Wounds  of  the  Spinal  Coed. 

Wounds  of  the  spinal  marrow  may  be  produced  by  gunshot  injuries,  by 
fractures  of  the  spinal  column  with  displacement,  or  by  pointed  instru- 
ments thrust  between  the  vertebrse.  The  symptoms  will  be  those  pre- 
viously detailed  as  occurring  in  injuries  and  inflammation  of  the  cord. 
They  will  vary  with  the  locality  of  the  wound.  Such  wounds,  involving 
a  limited  portion  of  the  diameter  of  the  cord  will  be  followed  by  a  limited 
paralysis,  corresponding  with  the  fibres  divided. 

The  treatment  of  wounds  of  the  cord  is  such  as  is  detailed  for  arresting 
and  treating  intraspinal  inflammation.  When  fragments  of  the  vertebra 
are  driven,  in  upon  the  cord  instrumental  elevation  is  justifiable,  but  the 
diagnosis  of  such  compression  is  often  difficult.  Exploratory  operation 
may  then  be  demanded. 

Concussion  or  Contusion,  and  Laceration  of  the  Cord. 

Shocks,  whether  direct  or  indirect,  to  the  spinal  column  are  not  trans- 
mitted to  the  cord  as  readily  as  similar  blows  are  to  the  brain,  because 
the  cord  hangs  loosely  in  the  canal,  and  is  surrounded  by  the  spinal  fluid. 
I  believe  that  cases  denominated  concussion  of  the  spine  are  really  in- 
stances of  contusion  or  laceration  of  the  cord  or  its  membranes  or  of 
extravasation  from  rupture  of  the  spinal  veins.  The  progressive  spinal 
symptoms  described  by  Erichsen  as  occurring  after  the  jarring  of  railway 
accidents,  and  attributed  by  him  to  so-called  spinal  concussion,  are,  in  my 
opinion,  probably  due  to  slight  contusion  or  laceration  of  the  contents  of 
the  spinal  canal. 

Contusion  and  similar  injuries  of  the  cord  require  treatment  adapted  to 
preventing  and  allaying  inflammation  of  this  nervous  centre. 

Neuritis,  or  InflAxMmation  of  Nerves. 

Causes. — Neuritis,  which  may  be  acute  or  chronic,  arises  from  expo- 
sure to  cold  and  wet,  wounds,  strains  causing  laceration  of  the  nerves, 
rheumatism,  gout,  and  syphilis.  Acute  neuritis  is  particularly  liable  to 
follow  laceration  of  nerve-trunks;  and  yet  nerves  may  often  be  exposed 
to  considerable  traumatic  irritation  without  becoming  inflamed. 

Pathology. — An  inflamed  nerve  shows  changes  in  the  neurilemma 
and  nerve-fibres.  Hyperaemia,  increased  connective  tissue,  serum,  lymph, 
and  pus  are  the  inflammatory  changes  associated  wdth  the  former ;  while 
granular  and  fatty  changes  follow^ed  by  softening  and  atrophy  occur  in 
the  latter.  In  acute  neuritis  the  nerve-trunk  is  swollen  from  the  depo- 
sition of  inflammatory  fluids,  and  pus  may  be  found  within  the  sheath. 


1  See  Surgery  of  the  Spinal  Cord,  by  Dr.  J.  "William  "White.    Annals  of  Surgery,  July, 


204  DISEASES    AND    INJURIES    OF    NERVES. 

If  the  nerve  is  superficial  a  Imrdened  cord  is  often  felt  beneath  the  skin. 
In  chronic  intlaniniation  an  increase  of  the  connective  tissue,  leading  to 
sclerosis  and  conse((uent  nerve  atrophy,  is  the  usual  pathological  change. 

.Symi'TOMS. — Intlaniniation  of  nerves  causes  disturbance  of  physiological 
function,  hence  the  symptoms  vary  as  the  nerve-trunk  is  motor,  sensory, 
or  mixed.  InHammation  of  nerves  of  special  sense,  such  a.s  the  optic  and 
auditory,  is  not  discussed  here,  but  belongs  to  the  domains  of  ophthal- 
mology and  otology. 

The  first  effect  of  inflammation  is  to  increase  the  irritability  of  nerves, 
but,  as  it  continues,  a  diminution  of  nervous  excitability  is  induced. 
Hence,  in  motor  neuritis,  twitching  and  spasm  of  the  muscles  occur  at 
the  time  of  invasion,  and  are  followed  by  paresis  or  complete  loss  of  jiower 
if  the  inflammation  is  not  speedily  arrested.  Sensory  neuritis  exhibits 
mainly  pain  and  hypersesthesia  followed  by  analgesia  and  anaesthesia. 
When  the  inflammatory  process  resides  in  a  mixed  nerve,  as  it  generally 
does  in  cases  met  by  surgeons,  these  classes  of  symptoms  are  combined. 
Reflex  influences  may  at  times,  however,  cause  the  appearance  of  symp- 
toms of  a  motor  character,  even  when  a  purely  sensory  nerve  is  inflamed. 
For  example,  neuritis  of  the  trifacial  will  be  accompanied  by  twitching 
of  some  of  the  muscles  of  the  face.  The  term  causalgia  is  applied  to  the 
peculiar  burning  i)ain  of  some  nerve  inflammations. 

Inflammation  as  found  in  neuritis  of  the  sciatic,  radial,  and  similar 
nerves,  then,  is  exhibited  by  pain,  of  a  remittent,  but  not  intermittent, 
character,  increased  by  pressure,  often  worse  at  night,  and  especially 
severe  when  due  to  traumatism.  There  will  perhaps  be  reflex  symptoms 
such  as  pain  in  other  parts  of  the  body.  The  painful  sensations  are  felt 
in  the  peripheral  distribution  of  the  nerve,  and  may  exist  even  when  the 
skin  has  become  anaesthetic.  Reflex  excitability  and  electric  contractility 
are  soon  diminished.  The  local  temperature  of  the  parts  supplied  is 
increased,  and  the  skin  over  the  course  of  the  trunk  is  red,  and  sometimes 
the  seat  of  a  bullous  eruption.  A  hard,  painful,  cord-like  swelling  is  felt 
along  the  course  of  the  trunk,  if  it  is  a  superficiul  nerve  that  is  involved. 
Clonic  spasms,  loss  of  power,  hyperresthesia,  anaesthesia,  and  atrophic 
changes  are  supplementary  symptoms. 

Fever  and  other  constitutional  symptoms  occur,  varying  in  intensity 
with  the  acuteness  of  the  neuritis. 

Chronic  neuritis  causes  much  less  pain,  but  the  other  functional  dis- 
turbances are  those  already  mentioned. 

Neuritis  may  spread  along  the  trunk  to  nerves  nearer  the  nervous  cen- 
tres. This  is  called  a.-^cending  neuritis.  In  a  similar  way  changes  may 
occur  above  and  spread  downward,  constituting  descending  neuritis.  Neu- 
ritis may  be  followed  by  ulceration,  deformity  of  joints,  and  other  second- 
ary pathological  conditions. 

DiAiiNOSis. — Neuritis  is  distinguished  from  neuralgia  by  the  continuous 
pain,  which  may  remit  but  docs  not  intermit ;  and  by  the  fact  that  the 
pain  is  usually  less  severe  than  the  paroxysmal  pain  of  neuralgia.  In 
neuralgia,  moreover,  there  is  not  the  local  elevation  of  temperature,  the 
muscular  spasm,  the  paralysis  of  motion  or  sensation  that  have  been 
mentioned  as  symptomatic  of  neuritis. 

Treatment. — Acute  neuritis  demands  absolute  rest  and  elevation  ot 
the  part,  ice-bags  locally,  and,  perhaps,  local  abstraction  of  blood.  Deep 
subcutaneous  injections  of  morphia  (grain  |  to  ^)  with  atropia  (grain  ^) 
over  the  painful  nerve,  and   the  application   of  the  primary  galvanic 


INJURIES    OF    NERVES.  205 

current  lias  been  useful.  The  general  disturbance  will  probably  necessi- 
tate at  the  same  time  the  use  of  diaphoretics  and  laxatives. 

Chi-ouic  inflammation  of  nerves  is  to  be  treated  by  blisters,  electricity, 
the  actual  cautery  and  increasing  doses  of  iodide  of  potassium.  Hypo- 
dermic injections  of  chloroform,  solutions  of  osmic  acid  or  of  cocaine 
may  at  times  be  serviceable.  Nerve-stretching  is  a  recently  introduced 
operation  for  chronic  pain  of  nerve-trunks.  The  nerve  is  exposed  by  an 
incision  and  stretched  by  being  forcibly  pulled  out  of  its  bed  by  the 
surgeon's  finger  or  a  hook. 

If  the  inflammation  is  due  to  rheumatism,  alkalies  and  salicylate  of 
sodium  are  indicated  ;  if  to  gout,  colchicum  ;  if  to  syphilitic  causes, 
mercury  and  iodide  of  potassium. 

The  actual  cautery  has  been  used  also  in  acute  neuritis  with  alleged 
benefit. 

The  atrophied  muscles  are  to  be  subjected  to  massage,  electricity, 
douches,  and  hypodermic  injections  of  strychnia  (grain  -^q). 

Tonics  and  similar  remedies  will  often  be  of  value  in  chronic  neuritis. 


Injuries  of  Nerves. 

Nerves  are  liable  to  be  bruised  and  lacerated  as  occurs  when  the  ulnar 
is  compressed  against  the  internal  condyle,  and  when  the  circumflex  is 
torn  in  dislocation  of  the  head  of  the  humerus. 

They  may  be  punctured,  incised,  completely  divided,  or  have  a  portion 
excised. 

Symptoms. — The  symptoms  in  such  injuries,  whether  open  or  subcuta- 
neous, vary  with  the  degree  of  damage  done  to  the  nerve-fibrils.  Slight 
contusions  cause  pain  at  the  point  of  injury  and  tingling  or  numbness 
along  the  peripheral  branches.  Other  wounds  give  rise  to  pain  followed 
by  paresis  or  paralysis.  Sometimes  pain  is  absent.  A  foreign  body 
impacted  in  a  nerve  is  apt  to  cause  spasmodic  action  of  the  muscles  in 
addition  to  the  pain  and  other  symptoms. 

Subsequent  to  the  receipt  of  injuiy  the  symptoms  of  neuritis  occur. 
Neuralgia  is  often  developed  as  a  sequel  to  nerve  wound.  This  is  espe- 
cially the  case  in  hysterical  subjects.  When  the  nerve  is  compressed  or 
dragged  upon  by  the  cicatrix  of  the  wound  in  the  other  tissues,  nutritive 
changes  take  place  in  the  parts  deprived  of  innervation.  These  consist  in 
atrophy  and  contracture  of  muscles  ;  alterations  in  the  nails  ;  and  changes 
in  the  skin,  which  may  become  shining  and  swollen  or  eczematous  ;  low- 
ered local  temperature  ;  loss  of  hair  ;  and  subacute  arthritis. 

The  ends  of  a  divided  nerve  retract,  become  bulbous  from  the  deposi- 
tion of  lymph,  and,  after  the  lapse  of  several  weeks  or  months,  are 
re-united  by  the  development  of  nerve  tissue,  thus  having  their  function 
restored.  This  will  at  times  happen  even  when  a  considerable  piece  of 
nerve  has  been  cut  out.  Hence,  when  it  is  desirable,  after  operation  for 
neuralgia  that  union  should  not  occur  it  is  necessary  to  excise  a  long  piece 
of  nerve  trunk  or  turn  back  the  distal  end.  Daring  the  period  required 
for  restoration  of  function  the  neighboring  nerves  seem  at  times  to  fulfil, 
in  part  at  least,  the  duties  of  the  injured  trunk  in  much  the  same  manner 
as  the  collateral  circulation  is  carried  on  when  an  artery  is  obstructed. 

Treatment. — Subcutaneous  nerve  injuries  need  only  such  treatment  as 
will  prevent  or  allaj^  the  resulting  neuritis.  Hypodermic  injections  of 
morphia  and  atropia,  cold,  or  perhaps  hot  applications,  and  galvanism 


206  DISEASES    AND    INJURIES    OF    NERVES. 

locallv,  with  iiuiuine  or  other  appropriate  remedies  internally,  are  judi- 
cious lueasii  res.  Other  local  remedies  of  value  are  belladonna  extract, 
menthol,  chloroform  and  aconitia,  used  as  lotions  or  ointment,  blisters, 
leeches,  and  tiie  actual  cautery.  In  open  wounds,  where  there  is  a 
tendency  to  considerable  separation,  union  can  very  properly  be  hastened 
by  suturing  the  extremities  together  with  catgut.  No  special  manner  of 
introducing  such  stitches  is  re<iuired,  if  only  approximation  is  accurately 
made. 

The  after-treatment  is  that  calculated  to  prevent  neuritis.  If  a  wound, 
in  which  there  was  a  large  nerve  divided  has  healed  and  permanent  i)aral- 
ysis  remains,  it  may  be  justifiable  to  expose  the  nerve,  cut  oti'  the  bulbous 
or  atrophied  extremities,  and  apply  sutures.  Considerable  success  has 
been  obtained  in  restoring  motion  to  limbs,  the  subject  of  traumatic 
paralysis  from  accidental  nerve  section.  Pieces  of  nerve  tissue  from  the 
rabbit  may  be  sutured  in  the  gaps  left  by  destruction  or  excision  of 
nerve  trunks. 

Neuralgia,  due  to  cicatricial  pressure,  is  treated  by  excising  the  innod- 
ular  tissue,  and  thus  getting  rid  of  the  scar  and  the  pinched  nerve.  Other 
neuralgias  after  nerve  injuries  require  the  treatment  detailed  in  the  article 
on  Neuralgia. 

Neuralfjla. 

Definition. — The  term  neuralgia  was  introduced  into  medical  language 
to  signify  pain  referred  to  the  course  of  a  nerve  without  ap|)arent  lesion. 
The  pain  was  said  to  be  functional.  Pathological  observation,  however, 
has  shown  that  many  instances  of  pain,  formerly  called  neuralgia,  are 
really  due  to  intiammation  or  compression  of  the  nerves,  or  to  other  defi- 
nite organic  changes.  Neuralgia  should,  therefore,  be  restricted  to  nerve 
pain  in  which  no  lesion  is  evident,  though  more  accurate  pathological 
knowledge  will  doubtless  still  further  lessen  the  cases  to  which  the  name 
is  appropriate. 

Neuralgia  then  may  be  defined  as  pain,  usually  paroxysmal,  situated 
not  in  the  brain  or  cord  but  in  the  nerves  themselves,  and  due  to  no  dis- 
coverable  organic  lesion. 

Causes. — The  chief  constitutional  cause  of  neuralgia  is  debility.  When 
the  powers  of  life  wane  from  old  age,  or  when  auEemia  exists  in  young  or 
old,  there  neuralgia  is  liable  to  appear  as  an  unwelcome  visitor.  Malaria 
is  a  very  frequent  cause  of  neuralgia,  especially  of  the  trifacial  nerve. 
Hysteria,  exposure  to  wet  and  cold,  retlex  irritation  from  uterine  disease, 
syphilis,  rheumatism,  and  gout  are  considered  factors  in  the  etiology  of 
neuralgia.  Some  of  these  probably  cause  nerve  pain  by  inducing  neuritis 
and  not  true  neuralgia.  The  same  fallacy  is  likely  to  underlie  cases  of 
neuralgia  attributed  to  diseased  teeth,  necrosis  of  bone,  and  periostitis. 
Compression  of  nerves  by  tumors  and  periostial  thickening  gives  rise  to 
neuralgic  pain. 

Symptoms. — The  most  frequent  situations  for  neuralgia  are  the  terminal 
branches  of  the  three  divisions  of  the  trifacial  nerve,  the  sciatic  nerve,  and 
the  intercostal  nerves.  Neuralgia  may  be  seated  in  a  number  of  small, 
nervous  twigs,  distributed  to  an  organ  or  surface  of  considerable  size ; 
thus,  we  have  neuralgia  of  the  breast,  of  the  te-iticle,  and  of  joints. 

The  pain  of  typical  neuralgia  is  sudden  and  paroxysmal.  It  occurs  as 
a  tearing,  darting  shock  or  ])ang  followed  by  an  interval  of  more  or  less 
complete  absence  of  pain.     In  many  instances  there  is  a  dull,  aching  pain 


NEURALGIA.  207 

continuously,  to  Avhich  are  added  at  irregular  intervals  the  painful  ex- 
acerbations. Muscular  exertion  generally,  and  jjressure  sometimes,  though 
not  usually,  aggravate  the  pain.  Xeuralgia  shows  quite  a  tendency  to  be 
unilateral,  and  often  there  is  exhibited  marked  cutaneous  hypersesthesia. 

Points  of  tenderness  on  pressure  can,  as  a  rule,  be  found  along  the 
course  of  the  nerve.  These  are  situated  where  the  nerve  passes  through 
a  bony  forarnen,  pierces  the  deep  fascia,  or  comes  near  the  surface  of  the 
body.  Occasionally  tenderness  is  exhibited  over  the  part  of  the  spinal 
cord  from  which  the  nerve  takes  its  origin. 

Local  muscular  spasm  is  found  associated  with  some  neuralgias,  as  are  at 
times  a  hot,  red,  swollen  skin  and  increased  secretion  of  the  neighboring 
lachrymal  or  salivary  glands.  The  peculiar  vesicular  eruption  called 
herpes  zoster  is  developed  over  the  line  of  a  neuralgic  nerve. 

Patients  who  have  once  suffered  with  neuralgia  are  liable  to  similar  ex- 
perience at  every  exposure  to  the  exciting  cause. 

The  location  of  the  neuralgia  may  vary  Avith  each  attack.  Indeed,  the 
pain  is  very  liable  to  change  from  one  nerve  to  another. 

Neuralgia,  particularly  of  the  trifacial  nerve,  is  often  very  intractable, 
but  it  is  not  a  disease  dangerous  to  life. 

Diagnosis. — It  is  easy  to  differentiate  a  typical  neuralgia  from  marked 
organic  disease.  There  are  no  alterations  in  shape  or  volume,  no  signs  of 
inflammation,  no  fever,  but  paroxysmal  pain,  cutaneous  hypersesthesia, 
and  a  history  of  debility,  malaria,  or  hysteria.  Firm  pressure  frequently 
relieves  neuralgic  pain,  if  it  is  continued  until  the  hypersesthetic  skin  has 
become  accustomed  to  the  contact  of  the  hand.  The  tendency  of  neuralgia 
to  be  transferred  from  one  nerve  to  another  is  a  valuable  point  in  diag- 
nosis. In  many  cases,  however,  neuralgia  can  only  be  presumed  to  exist, 
because  the  pain  cannot  be  attributed  to  any  other  affection.  Muscular 
and  fascial  pains  due  to  rheumatism  or  syphilis  are  often  mistaken  for 
neuralgia. 

Treatment. — As  the  constitutional  condition  underlying  neuralgia  is 
usually  either  debility  or  malaria,  quinine  and  its  congeners  are  the  most 
useful  internal  remedies  that  we  have.  Quinine  should  be  given  in  full 
doses  even  when  no  malarial  history  can  be  obtained.  Twenty  to  thirty 
grains  in  the  twenty-four  hours  may  be  curative  when  less  doses  have 
accomplished  nothing.  If  this  drug  fails,  recourse  should  be  had  to 
arsenic.  The  solution  of  arsenite  of  potassium  should  be  given  in  doses 
of  five  to  ten  minims  three  times  daily  after  eating,  and  be  gradually  in- 
creased. The  same  preparation  may  be  employed  hypodermically  in 
about  half  this  amount,  diluted  with  water  and  also  increased  by  degrees. 
Iron,  strychnia,  and  cod-liver  oil  in  large  doses  frequently  repeated,  gal- 
vanism, good  nutritious  diet,  fresh  air,  sea  bathing,  change  of  scene  and 
climate  are  valuable  agents  in  combating  the  tendency  to  neuralgia.  In 
hysterical  subjects,  valerian,  bromide  of  potassium,  and  assafoetida  may  be 
available ;  in  rheumatic  cases,  alkalies ;  in  those  of  gouty  diathesis,  col- 
chicura  ;  and  in  syphilitics,  iodide  of  potassium  or  mercury.  Ergot  and 
phosphorus  have  been  recommended  by  high  authority. 

Uterine  or  other  affections  giving  rise  to  neuralgia  by  reflex  influence 
should  be  remedied  by  appropriate  measures. 

To  relieve  an  attack  of  neuralgia,  when  present,  morphia,  atropia, 
chloral,  hyoscyamus,  bromide  of  potassium,  alcohol  and  the  inhalation  of 
anaesthetics  have  a  positive  value.  The  use  of  such  remedies  is  to  be 
deprecated  and  their  repetition  avoided  as  far  as  practicable,  because  of 
the  early  necessity  of  increasing  the  dose  and  the  liability  of  inducing  in- 


208  DISEASES    AND    INJURIES    OF    NERVES. 

temperance  in  their  employment.  Neuralgic  patients,  for  this  reason, 
should  not  be  informed  of  the  name  of  the  remedy  administered.  Aconitia 
may  be  given  in  doses  of  gr.  t7^„  and  gradually  and  very  cautiously  in- 
creased. The  benumbing  eliect  of  this  powerful  drug  on  the  peripheral 
nerve  is  well  known.     ^Menthol  locally  gives  at  times  relief 

The  local  treatment  of  neuralgia  deserves  attention.  Any  suspected 
local  cause,  such  as  diseased  teeth  or  cicatricial  ])ressure,  should  be  re- 
moved. In  many  of  these  instances,  however,  the  pain  is  probably  due  to 
a  neuritis  and,  hence,  is  not  true  neuralgia.  Hypodermic  injection  of 
morphia  (gr.  -g^-gr.  1 )  into  the  nerve  trunk  or  in  its  immediate  neighbor- 
hood is  a  potent  remedy  and  may  not  only  palliate,  but  by  repetition  even 
cure.  The  needle  of  the  syringe  should  be  thrust  deeply  into  the  tissues 
and,  if  possible,  iuto  the  nerve.  Atropia  (gr.  yV~g''*  iV)  ^^lone  or  com- 
bined with  morphia,  ether  (n\_  x-xxx\  chloroform,  or  bromide  of  ethyl, 
or  solution  of  osmic  acid  may  be  employed  in  a  similar  manner.  These 
and  other  sedatives  may  also  be  used  in  the  form  of  liniments  and  oint- 
ments. x\.conitia  (gr.  v  to  5J  of  ointment),  veratria  (gr.  xx  to  5J  of  oint- 
ment), and  menthnl  are  often  very  efficacious  local  applications.  Heat 
and  cold  vary  in  different  cases  as  to  the  amount  of  relief  they  afford. 
The  primary  galvanic  current  is  at  times  useful.  Blisters,  strong  water 
of  ammonia,  the  actual  cautery,  and  similar  counter-irritants  have  a 
positive  value  in  some  instances.  Acupuncture  and  galvano-puncture 
have  been  recommended. 

Nerve-stretching,  nerve-section  (neurotomy),  and  nerve-excision  (neu- 
rectomy) are  proper  surgical  expedients  only  when  the  neuralgia  is  verv 
severe  and  intractable. 

Nerve-stretching  is  performed  by  making  an  incision  over  the  trunk,  iso- 
lating it  and  lifting  it  out  of  its  bed  by  a  hook  or  the  fingers.  Strong 
traction  is  then  made  upon  it  in  the  direction  of  the  peripheral  branches, 
that  is,  away  from  the  cerebro-spinal  end,  a  considerable  increase  in  the 
length  of  the  loop  is  apparent.  If  the  operation  is  done  without  ether, 
or  if  only  local  ansesthesia  has  been  employed,  the  traction  is  to  be  con- 
tinued until  numbness  of  the  periphery  is  experienced  by  the  patient. 
The  operation  is  only  painful  on  account  of  the  cutaneous  or  muscular 
incisions.  The  numbness  and  paresis  of  the  parts  to  which  the  nerve  is 
distributed  soon  pass  away.  Nerve-stretching  has  accomplished  many 
cures  of  neuralgia.  It  has  also  been  done  for  spasm  of  muscles.  Strong 
compression  of  a  nerve  against  a  bone  or  by  a  screw  clamp  may  relieve 
neurajgia  by  crushing  the  nerve  fibrils. 

Simple  section  of  a  nerve  is  of  little  value  in  obstinate  neuralgia, 
because  union  soon  takes  place ;  hence,  excision  of  one  or  two  inches  is 
much  more  successful.  The  neurectomy  or  excision  should  remove  a  por- 
tion of  nerve  as  far  as  possible  behind  the  seat  of  pain,  for  this  gives  the 
best  chance  of  getting  above  the  seat  of  pathological  changes.  The  distal 
end  of  the  divided  nerve  may  be  turned  back,  or  a  portion  of  muscle  may 
be  interposed  between  the  ends  to  prevent  union  and  recurrence  of  pain. 
If  the  neuralgia  depends  upon  peripheral  nerve  change,  these  operations 
are  usually  permanently  beneficial ;  but  if  the  pain  arises  from  altera- 
tions in  the  nerve  centres,  nerve-stretching  and  neurectomy  give  only  tem- 
porary comfort.  The  absence  of  pain  for  several  months,  however,  is 
often  a  great  boon.  The  palsy  after  neurectomy  is  generally  permanent. 
It  has  been  suggested  to  cut  out  the  cortical  brain  centre,  from  wdiich  the 
painful  nerve  has  its  origin,  if  this  can  be  determined  by  central  locali- 
zation. 


TETANUS.  209 

The  three  divisions  of  the  trifacial  are  often  excised.  The  supraorbital 
nerve  is  reached  by  an  incision  along  the  supraorbital  arch,  after  which 
the  nerve  should  be  cut  off  as  far  back  in  the  orbit  as  possible.  If  the 
nerve  comes  through  a  distinct  foramen,  this  foramen  may  be  converted 
into  a  groove  by  cutting  out  the  edge  of  the  bone  with  a  chisel  and  then  a 
hook  can  be  passed  above  the  globe  of  the  eye  so  as  to  enable  the  surgeon 
to  drag  the  nerve  forward.  The  infraorbital  may  be  reached  in  a  similar 
manner;  by  trephining  both  the  anterior  and  posterior  wall  of  the  antrum 
this  nerve  may  be  cut  off"  close  to  the  exit  of  the  main  trunk  from  the 
round  foramen  in  the  sphenoid  bone.  It  can  be  torn  off  nearly  this  far 
back  by  swiftly  cutting  away  with  a  chisel  the  edge  of  the  orbit  and 
seizing  it  with  strong  forceps  in  the  floor  of  the  orbit.  The  inferior  dental 
is  best  reached  by  trephining  the  ramus  of  the  lower  jaw  and  exposing 
the  nerve  in  its  canal.  Another  method  is  to  lay  bare  the  mental  foramen, 
and  by  means  of  the  disk  of  the  surgical  engine,  or  with  chisels,  to  remove 
the  roof  of  the  inferior  dental  canal  as  far  back  as  is  deemed  necessarv. 
It  must  be  recollected  that  the  alveolar  process  in  old  persons,  in  whom 
these  operations  are  especially  debaanded,  is  generally  absorbed,  and  the 
canal  is  relatively  further  from  the  lower  border  of  the  bone  than  in 
young  adults. 

Tetanus. 

Definition. — Tetanus  is  a  disease  characterized  by  persistent  and 
painful  muscular  contraction  due  to  abnormal  excitability  of  the  medulla 
oblongata  and  spinal  cord,  which  is  probably  dependent  upon  inflamma- 
tion of  the  central  gray  matter  of  these  organs. 

Pathology. — The  weight  of  evidence  was  until  recently  in  favor  of 
considering  tetanus  a  disease  of  the  nervous  system,  and  not  a  blood 
affection,  due  to  the  introduction  of  some  poisonous  agent  into  the  circu- 
lation. The  pathological  condition  was  thought  to  be  probably  inflamma- 
tion of  the  gray  matter  of  the  medulla  oblongata  and  spinal  cord. 
Hypersemia,  extravasation,  exudations,  and  softening  have  been  detected, 
especially  in  the  posterior  horns  of  gray  matter  and  in  their  immediate 
vicinity.  When  the  disease  is  caused  by  injuries  to  the  lower  extremities 
these  changes  are  said  to  be  found  in  the  lumbar  enlargement ;  when  the 
wound  is  situated  upon  an  upper  extremity,  in  the  cervical  enlargement 
of  the  cord.  Sometimes  the  nerves  in  the  neighborhood  of  the  wound  are 
found  inflamed,  but  this  peripheral  neuritis  does  not  seem  to  be  an  essen- 
tial lesion.  The  most  recent  investigations  seem  to  mdicate  the  probability 
that  tetanus  is  due  to  a  microorganism,  which  would  explain  its  occasional 
contagiousness  and  many  points  in  its  clinical  history. 

Causes. — Traumatism  is  the  usual  exciting  cause  of  tetanus,  but  it 
may,  especially  in  hot  climates,  occur  idiopathically.  The  latter  is  some- 
times termed  rheumatic  tetanus.  Occasionally  tetanus  seems  to  be 
endemic. 

A  sudden  change  from  a  high  to  a  low  temperature,  with  dampness,  is 
liable,  especially  in  military  practice,  to  be  followed  by  cases  of  traumatic 
tetanus.  Traumatic  tetanus  often  occurs  in  vigorous  patients  who  have 
sustained  injuries,  but  it  is  probably  more  frequent  in  those  of  lowered 
nervous  tone  from  shock,  hemorrhage,  deprivation  of  food,  and  want  of 
fresh  air.  It  is  said  to  be  more  common  in  the  negro  than  in  the  white 
race.  There  is  no  direct  relation  between  the  severity  of  the  injury  and 
the  tetanic  symptoms.     The  slightest  bruise,  puncture  or  surgical  opera- 

14 


210       DISEASES    AND    INJURIES    OF    NERVOUS    CENTRES. 

tion  may  be  followed  by  the  most  violent  form  of  tetanus.  Burns  and 
lacerations  are  more  apt  to  give  rise  to  this  complication  than  incised 
wound.^.  It  is  doubtful  whether  wounds  of  the  feet  and  hands  are 
especially  prone  to  cause  tetanus,  thougli  some  authorities  believe  that 
such  is  the  ctise.  Tetanus  in  newly-born  infants  has  been  ascribed  to  the 
ligation  of  the  umbilical  cord,  and  to  pressure  upon  the  cranial  bones 
during  birth. 

Symptoms. — The  symptoms  of  idiopathic  tetanus  are  identical  with, 
though  usually  less  severe  than,  those  of  the  traumatic  form.  The  treat- 
ment is  the  same  in  both  varieties,  except  that  in  one  attention  to  the 
wound  is  required. 

The  time  of  appearance  of  traumatic  tetanus  is  usually  from  five  to  ten 
days  after  the  receipt  of  the  injury;  though  the  initiatory  symptoms  may 
be  exhibited  in  a  few  hours,  or  delayed  until  several  weeks  have  elapsed. 
The  early  cases  are  apt  to  be  more  acute  in  their  progress,  violent  in  symp- 
toms, and  fatal  in  prognosis.  Digestive  disorders,  or  general  and  indefi- 
nite uneasiness  may  perhaps  be  observed,  or  possibly  the  wound  may 
become  dry  and  unhealthy  before  the  characteristics  of  tetanus  are  devel- 
oped. In  many  instances,  however,  nothing  unusual  attracts  attention 
until  stiffness  and  pain  iu  the  muscles  of  mastication  or  pain  in  the  epi- 
gastrium, proclaim  the  advent  of  this  serious  complication.  It  is  rarely 
that  the  muscular  spasm  shows  itself  primarily  in  the  wounded  limb. 
Pain  in  the  epigastrium  from  spasm  of  the  diaphragm,  or  painful  rigidity 
of  the  muscles  that  close  the  mouth  and  of  the  back  of  the  neck,  is  the 
usual  initiatory  symptom.  The  muscles  thus  primarily  affected  are  those 
supplied  by  the  motor  branch  of  the  trifacial  nerve,  the  facial,  and  the 
spinal  accessory  nerves.  The  muscular  spasm  is  continuous,  or  tonic, 
though  there  are  occasional  paroxysms  of  increased  contraction.  The 
contraction  is  exceedingly  powerful.  The  voluntary  muscles,  except  those 
of  the  hands,  feet,  eyeball,  and  tongue,  generally  become  rigid  soon  afler 
the  iucipiency  of  the  disease.  The  epigastric  pain  is  attributed  to  spasm 
of  the  diaphragm,  and  it  is  believed  by  some  that  death  may  occur  from 
cardiac  spasm.  These  are  possible  examples  of  the  tetanic  spasm  occui*- 
ring  in  muscles  of  involuntary  innervation.  The  pain  accompanying  the 
muscular  spasm  is  severe,  resembles  that  of  ordinary  cramps,  and  shows 
exacerbations  at  the  times  when  the  rigidity  increases.  AVhen  the  poste- 
rior muscles  are  more  especially  affected  the  patient's  head  and  legs  are 
bent  backward,  until  he  assumes  such  an  arched  position  that,  if  placed 
in  the  supine  posture,  only  his  occiput  and  heels  would  touch  the  bed. 
This  condition  is  called  opisthotonos.  The  term  em])r()Sthotonos  is  em- 
ployed to  designate  a  similar  flexion  forward,  and  pleurothotonus  to  denote 
lateral  deflection.  Opisthotonos  more  or  less  marked  is  the  common  pos- 
ture ;  the  others  are  very  rare.  The  inability  to  open  the  mouth  gives 
tetanus  the  popular  name  of  locked-jaw.  The  medical  term  for  the  spasm 
of  the  jaw  muscles  is  trismus.  The  power  of  tetanic  spasm  must  be  seen 
to  be  appreciated.  Muscles  may,  at  times,  be  ruptured  by  the  violent 
contraction,  and  the  patient  becomes  unconscious  from  the  unendurable 
pain. 

The  patient  suffers  from  difficulty  in  swallowing,  dyspnoea,  and  sleep- 
lessness. There  is  sometimes  aphonia,  and  occasionally  the  tongue  is 
bitten  by  a  sudden  paroxysmal  spasm  of  the  temporal  muscle.  6a  ac- 
count of  this  danger  the  surgeon  should  avoid  requesting  the  protrusion 
of  the  tongue.  Viscid  saliva  may  collect  in  the  mouth  and  annoy  the 
patient.     The  mind  is  perfectly  clear,  but  the  facial  expression  is  charac- 


TETANUS.  211 

t  eristic.  The  sardonic  grin  of  tetanus,  as  it  is  called,  consists  in  retrac- 
tion and  elevation  of  the  corners  of  the  mouth,  closed  teeth,  transverse 
furrowing  of  the  forehead,  dilatation  of  the  nostrils,  and  a  fixed,  anxious 
expression  of  the  eyes.  Constipation  and  retention  of  urine  are  usually- 
present.  Reflex  excitability  is  so  great  that  the  noise  of  a  suddenly  closed 
door,  a  draft  of  air,  the  touch  of  the  surgeon's  hand,  or  a  flash  of  light  may 
induce  an  exacerbation  of  spasm.  Respiration  is  embarrassed  and  quick- 
ened, and  the  pulse  feeble.  In  the  early  stage  there  is  little  fever,  but 
toward  the  termination  of  the  disease  high  temperature  and  profuse 
sweating  are  not  infrequent.  Instances  of  very  high  temperature  have  been 
observed,  and  cases  have  been  reported  in  which  the  bodily  heat  rose  even 
after  death. 

The  exhaustion  arising  from  the  continuous  muscular  action  is  very 
great,  and  is  often  the  cause  of  death,  before  which  relaxation  may  take 
place.  The  fatal  issue  may  occur  from  spasm  of  the  respiratory  muscles, 
and  possibly  from  spasm  of  the  heart.  Fatal  cases  terminate  usually  in 
from  three  to  five  days. 

Diagnosis. — Local  rigidity  of  the  masticatory  muscles,  due  to  cold,  or 
diseased  teeth,  is  distinguished  from  tetanus  by  the  absence  of  pain,  the 
non-occurrence  of  paroxysmal  increase  of  spasm,  the  absence  of  hardness 
of  the  abdominal  muscles  and  of  other  tetanic  symptoms,  and,  finally,  by 
its  curability,  particularly  after  removing  the  cause.  Spinal  meningitis 
has  a  different  history,  gives  rise  to  rigidity  of  the  extremities  and  neck, 
rather  than  to  trismus,  and  is  followed  by  paralysis. 

In  hydrophobia  we  see  a  convulsed  and  restless  face  instead  of  the  knit 
brow  and  grinning  mouth  of  tetanus.  Moreover,  there  is  delirium,  and 
the  spasms  are  intermittent  or  clonic.  The  profuse  secretion  of  saliva 
and  the  convulsive  attacks  following  attempts  at  deglutition  are  not  a  part 
of  the  clinical  history  of  tetanus. 

Hysteria  assumes  the  characteristics  of  tetanus.  It  may  be  differentiated 
by  considering  the  sex  and  character  of  the  patient,  and  by  observing  the 
absence  of  pain,  the  intermission  or  irregularity  of  the  tonic  rigidity,  and 
the  transient  nature  of  the  spasm  w^hen  the  application  of  the  actual  cau- 
tery is  suggested. 

Strychnia  poisoning,  particularly  when  produced  by  the  repeated  admin- 
istration of  small  toxic  doses,  greatly  resembles  tetanus.  Here,  however, 
spasm  occurs  in  the  limbs  sooner  than  in  the  jaw,  epigastric  pain  is  absent, 
and  opisthotonos  arises  at  an  earlier  time  than  in  tetanus.  There  is, 
moreover,  no  history  of  traumatism,  which,  however,  is  absent  also  in 
idiopathic  tetanus.  In  most  cases  of  strychnia  poisoning,  death  or 
recovery  occurs  within  a  short  period  ;  and  there  can  usually  be  elicited 
a  suspicious  history  of  suicide  or  homicide. 

Prognosis. — Tetanus  arising  within  nine  days  of  the  time  of  injury  is 
almost  invariably  fatal.  Recoveries  from  tetanus,  which  are  rare,  are 
usually  instances  of  the  disease  that  have  arisen  nine  days  or  more  after 
the  receipt  of  injury,  and  that  have  shown  symptoms  of  but  moderate 
violence.  If  the  patient  survives  the  fourteenth  day  of  tetanus,  recovery 
may  be  expected.     High  temperature  is  an  unfavorable  symptom. 

Treatment. — Although  the  death-rate  of  tetanus  is  very  high,  treat- 
ment that  lessens  peripheral  irritation  and  diminishes  spinal  excitability 
always  palliates  suffering,  and  may  at  times  be  followed  by  cure.  The 
patient  should  be  kept  in  a  quiet,  darkened  room,  free  from  draughts  of  air, 
and  should  be  supplied  with  concentrated  liquid  food  because  of  the  ex- 
haustive character  of  the  disease.     Food  can  be  introduced  by  a  flexible 


212      DISEASES    AND    INJURIES    OF    NERVOUS    CENTRES. 

tube  passed  between  the  cheek  aud  the  teeth,  so  that  the  liquid  may  enter 
the  niouth  l)ehind  tlie  molars  ;  or  by  a  similar  tube  passed  into  the  pharynx 
through  the  nostril.  Usually,  however,  there  are  crevices  between  the 
teeth  which  admit  the  entrance  of  milk  or  soup.  .Such  alimentation  is 
preferable  to  rectal  feeding,  though  the  introduction  of  partially  digested 
liquid  food  into  the  rectum  may  be  valuable.  Freedom  from  noise  may 
be  obtained  by  putting  cotton  in  the  patient's  ears. 

Iron,  quinine,  and  stinmlants  may  be  de.sirable  to  sustain  the  failing 
powers.  Laxatives  or  enemas  may  be  required.  Active  purgation  is  in- 
jurious. The  best  remedy  to  control  reHex  excitability  is,  in  my  opinion, 
hydrate  of  chloral,  which  should  be  given  in  ten  or  twenty  grain  doses 
every  one,  two,  or  three  hours.  These  doses  may  be  increa.sed  if  the 
patient  does  not  become  quiet  and  sleep.  I  have  had  good  results  follow 
this  treatment,  but  it  must  be  admitted  that  the  cases  were  not  of  the 
most  violent  type.  Extract  of  physostigma  (gr.  j  every  two  hours  and 
increased),  or  its  active  principle,  eserine,  hyoscine,  urethan,  etc.,  are 
worthy  of  consideration  if  chloral  in  large  doses  does  not  seem  satisfactory. 
These  remedies  should  be  given  early,  and  in  doses  as  large  as  experience 
shows  can  be  tolerated  before  resorting  to  other  drugs.  Chloral  has  been 
successfully  used  by  enema,  and  eserine  is  very  readily  administered  by 
hvpodermic  injection.  0[)ium  has  some  reputation  in  the  treatment  of 
tetanus,  but  it  is  probably  better  to  use  it  as  an  adjunct  to  the  chloral,  to 
relieve  pain,  liromide  of  potassium,  cannabis  indica,  conium  and  similar 
substances,  and  the  inhalation  of  amesthetics  have  been  advocated. 

Hammond  strongly  recommends,  in  addition  to  internal  treatment,  the 
application  of  the  ice-bag  to  the  spine.  Local  measures  .should  be  adopted 
to  prevent  peripheral  irritation.  The  wound  should  be  freed  from  foreign 
bodies  impacted  in  it,  made  aseptic,  and  dressed  with  antiseptic  gauze. 
Stretching,  incision,  and  excision  of  the  nerve  trunks  have  been  employed, 
as  has  amputation,  with  varying  results.  When  the  nerve  supply  cannot 
be  definitely  fixed  it  has  been  proposed  to  make  a  deep  incision  down  to 
the  bone  and  thus  divide  all  the  nervous  filaments.  All  these  operations 
are  regarded  as  of  doubtful  expediency  by  most  authorities,  though  they 
are,  perhaps,  justifiable  in  such  a  hopeless  condition.  As  such  operations 
cannot  be  resorted  to  until  tetanus  has  arisen,  and  as  the  symptoms  prob- 
ably depend  upon  a  microbic  cause,  I  doubt  the  utility  of  their  perform- 
ance. Neurectomy  is  apparently  the  most  judicious  procedure  if  an}'' 
operation  is  done.  Tracheotomy  has  been  advised  to  meet  the  possibility 
of  death  by  laryngeal  spasm. 

Hydrophobia. 

Definition. — Hydrophobia  is  a  disease  of  fatal  prognosis,  character- 
ized by  sudden  spasm  of  the  respiratory  muscles  upon  attempts  at  deglu- 
tition and  by  other  nervous  phenomena,  and  which  is  generally  believed 
to  be  a  blood  di.sease  due  to  inoculation  with  a  specific  virus  contained  in 
the  oral  secretions  of  rabid  animals,  though  there  is  some  evidence  sug- 
gestive of  the  symptoms  being  manifestations  of  central  nervous  di-sease, 
initiated  in  traumatic  ca.ses  by  the  i^eripheral  irritation  of  the  injured 
nerve  branches. 

Cause. — If  the  generally  accepted  theory  be  correct,  the  cause  of  hy- 
drophobia is  a  peculiar  poison  contained  in  the  secretions  of  the  mouth 
of  animals  affected  with  rabies.     The  disease  is  believed  to  be  generated 


HYDROPHOBIA.  213 

spontaneously  only  in  the  canine  family,  in  the  cat,  and  a  few  other 
animals ;  but  it  can  be  communicated  by  inoculation  to  others,  whose  oral 
secretions  then  become  yirulent.  It  has  not  been  proved  that  it  can  be 
communicated  from  one  human  being  to  another.  Innoculation  with  other 
fluids  of  affected  animals  does  not  produce  the  disease.  It  has  been  sug- 
gested that  bites  by  female  animals  in  heat  are,  perhaps,  more  likely  to 
cause  hydrophobia  than  those  of  males  or  females  under  other  circum- 
stances. Microorganisms  have  been  described  as  found  in  the  secretions 
from  the  mouths  of  rabid  animals,  and  to  these  fungi  the  communicability 
of  the  disease  has  been  attributed.  Many  persons  bitten  by  rabid  dogs 
experience  no  unusual  sequences,  possibly  because  the  saliva  was  absorbed 
bv  the  clothing  through  which  the  injury  was  inflicted. 

Another  theory  of  the  obscure  disease  called  hydrophobia  is  that  it  is 
a  reflex  neurosis ;  in  other  words,  that  the  wound,  for  hydrophobic  symp- 
toms are  usually  consecutive  to  a  wound,  causes  irritation  of  the  peripheral 
nerves,  which,  in  turn  leads  to  molecular  and  vascular  changes  in  the 
medulla  oblongata  and  pons  Varolii. 

If  this  theory  is  true,  it  follows  that  hydrophobic  symptoms  can 
probably  occur  after  other  peripheral  irritation  than  that  of  bites  of 
rabid  animals.  In  fact  they  could  arise  when  no  injury  had  been  received, 
provided  the  necessary  changes  in  the  medulla  oblongata  and  pons 
Varolii  were  incited.  There  is  some  evidence  that  seems  to  point  in  this 
direction. 

Pathology.: — Changes,  such  as  congestion,  extravasation,  softening, 
and  granular  degeneration  have  been  found  in  the  medulla  oblongata, 
cord,  and  brain  of  patients  dying  with  hydrophobia.  These  lesions  are 
apt  to  be  conspicuous  in  the  medulla  oblongata  and  its  vicinity.  They 
may,  however,  be  secondary,  and  not  the  essential  morbid  changes  of  the 
disease.  In  some  instances  chronic  alterations  have  been  discovered  in 
the  nervous  centres,  which  may  have  been  the  cause  of  the  susceptibility 
to  hydrophobic  symptoms  when  peripheral  irritation  was  induced.  These 
cases  seem  to  support  the  second  theory  of  the  nature  of  hydrophobia. 

Symptoms. — Rabies  is  first  exhibited  in  dogs  by  listlessness  followed  by 
restlessness,  but  there  is  no  disposition  to  bite.  Afterward  the  animal 
may  become  excited,  as  is  exhibited  by  barking  in  a  hoarse  tone  and  snap- 
ping at  the  air,  biting  and  licking  sticks  and  stones  ;  or  he  may  show 
symptoms  of  melancholy  and  refuse  to  eat,  drink,  or  observe  his  sur- 
roundings. Paroxysmal  excitement,  spasm  of  respiration  and  deglutition, 
protruding  tongue  and  constant  escape  of  saliva  from  the  mouth,  paral- 
ysis of  the  legs,  convulsions  and  tremors  may  precede  death.  Rabies  is 
not  more  common  in  summer  than  in  other  seasons,  nor  do  mad  dogs 
have  the  dread  of  water  which  is  exhibited  by  men  with  hydrophobia. 
Much  of  the  animal's  excitement  is  doubtless  in  many  cases  due  to  his 
being  chased  by  persons  desirous  of  destroying  him. 

In  man  the  period  of  incubation  is  usually,  it  is  said,  not  longer  than 
seven  months.  Cases  have  been  reported  "when  only  a  few  days  elapsed, 
and  others  are  recorded  in  which  no  symptoms  were  shown  until  years 
had  passed.     Many  of  these  cases  will  not  bear  searching  investigation. 

The  wound  made  by  the  teeth  of  the  rabid  dog  usually  heals  readily  ; 
but  may,  just  before  the  advent  of  the  general  symptoms,  become  the 
seat  of  stinging  pain  or  of  inflammation. 

The  initiatory  symptoms  are  physical  and  mental  discomfort,  stiffness 
of  the  throat  and  tongue,  anxiety  and  irritability  of  disposition.  Then 
occur  spasms  of  muscles  of  deglutition  and  respiration,  especially  when 


214      DISEASES    AM)    INJURIES    OF    NERVOUS    CENTRES. 

attempts  at  swallowing  water  and  other  fluids  are  made.  This  symptom 
gives  the  name  to  the  disease.  Solids  are  swallowed  more  readily  than 
fluids.  Cutaneous  and  sensory  hy|)enesthesia,  wild  delirium,  convulsed 
features,  hawking  and  spitting  of  an  abundant  viscid  fluid,  attacks  of 
suttbcation  caused  by  drafts  of  air  and  attempts  at  deglutition,  hoarse 
cough,  sleeplessness,  maniacal  excitement,  and  at  times  paralysis,  or 
general  tetanoid  or  epileptoid  convulsions  complete  the  distressing  picture. 
The  pulse  is  frequent,  the  temperature  high,  and  the  urine  often  albu- 
minous or  saccharine.  Death  occurs  from  spasm  or  exiuiustion  about  the 
third  day. 

It  is  said  that  dread  of  water  is  not  always  present,  and  that  this  symp- 
tom may  occur  in  other  aflTections. 

DiACiNOSis. — Hydrophobia  sometimes  much  resembles  tetanus,  and, 
indeed,  a  variety  of  the  latter  disease  has  been  described  as  hydrophobic 
tetanus.  The  difl'erential  diagnosis  of  tetanus  and  hydrophobia  has  been 
discussed  in  the  ])receding  article.  Hysteria  may  assume  the  asj)ect  of 
hydrophobia,  but  there  is  a  want  of  consistency  in  the  symptoms  and  an 
absence  of  high  temperature.  Moreover,  the  hydrophobic  patient  tries  to 
conceal  his  fears  from  his  friends,  while  the  hysterical  one  endeavors  to 
call  attention  to  them.  Hysterical  hydrophobia  is  developed  soon  after 
the  injury. 

Treatment. — The  preventive  measures,  to  be  adopted  after  an  injury 
has  been  inflicted  by  the  teeth  of  a  mad  dog  or  other  animal  is  the  im- 
mediate excision  of  the  tissues  around  the  wound,  or  silction  followed  by 
cauterization  with  strong  nitric  acid,  or  better  with  the  red-hot  iron. 
The  application  of  a  tight  bandage  to  the  limb  above  the  wound  until 
excision  or  cauterization  has  been  effected  is  proper.  The  fears  of  the 
patient  may  be  allayed  by  these  precautions,  even  if  the  time  elapsed  has 
been  too  considerable  to  give  an  opportunity  to  prevent  absorption  by 
such  means.  I  believe  the  application  of  nitrate  of  silver  to  be  perfectly 
valueless.  The  animal  should  never  be  killed,  but  kept  in  confinement 
that  the  existence  of  rabies  may  be  verified  or  disproved.  Bromide  of 
potassium  in  large  doses  has  been  recommended  during  the  period  of 
latency.  When  the  symptoms  have  apjieared,  treatment,  as  a  rule,  exerts 
little  influence  in  averting  death.  Nourishment  and  perhaps  stimulation 
by  the  rectum,  ice  to  the  spine,  perfect  quiet  and  freedom  from  excitement 
are  indicated.  Worara  (grain  yV  ^^  i)  or  pilocarpine  (grain  \  to  \) 
given  hypodermically,  nitrite  of  amyl  or  chloroform  by  inhalation,  chloral, 
morphine  and  bromide  of  ])otassium,  hyoscine  hydrobromate,  and  similar 
remedies  may  be  tried,  but  must  be  employed  in  large  doses. 

Pasteur  has  shown  that  dogs  and  some  other  animals  may  be  protected 
from  rabies  by  inoculation  with  attenuated  virus  of  rabies  in  much  the 
same  way  as  men  are  jirotected  from  smallpox  by  vaccinatit)n.  He  has 
asserted  that  human  beings  who  have  been  bitten  by  rabid  animals  may 
be  protected  from  the  disease  by  a  similar  preventive  inoculation.  His 
views  have  not  as  yet  been  accepted  by  the  entire  medical  world. 

Traumatic  Delirium  Tremens. 

Definition. — This  is  a  nervous  aflection  characterized  by  muscular 
tremor  and  a  peculiar  restless  delirium,  which  not  infrequently  follows 
the  receipt  of  injuries  by  those  accustomed  to  alcoholic  stimulation. 

Cause.s. — Some  writers  under  the  terms  traumatic  delirium  and  nervous 


TRAUMATIC    DELIRIUM    TREMEN'S.  215 

delirium  describe  a  condition,  frequently  very  similar  to  delirium  tremens, 
which  is  said  to  occur  in  patients  free  from  the  alcohol  habit  and  to  de- 
pend upon  nervous  prostration,  often  associated  with  shock  and  hemor- 
rhage. It  is  possible  that  failure  to  investigate  previous  habits  with 
judicial  acumen  has  allowed  to  arise  a  confusion  between  delirium  de- 
pendent simply  upon  traumatism  and  delirium  induced  by  traumatism  in 
alcohol  drinkers.  The  muttering  delirium  and  muscular  twitching  that 
supervene  in  nervous  prostration  or  asthenia  from  surgical  as  from  medi- 
cal causes,  and  the  noisy  delirium  after  injury,  that  is  usually  exhibited 
by  quick,  rapid,  and  full  pulse  and  by  febrile  reaction,  are  two  very 
different  conditions  to  which  the  name  traumatic  delirium  may  with  pro- 
priety be  applied.  These  forms  of  mental  disturbance — better  in  my 
opinion  called,  in  the  one  case,  nervous  or  asthenic  traumatic  delirium, 
and,  in  the  other  case,  septic  or  inflammatory  traumatic  delirium — arise 
without  reference  to  personal  habits.  These  two  conditions  are  possibly 
often  intermingled  with  alcoholic  traumatic  delirium  or  traumatic  delirium 
tremens,  as  I  here  term  it. 

The  group  of  symptoms  which  I  propose  describing  as  traumatic 
delirium  tremens,  is  found  especially,  if  not  exclusively,  indeed,  in  those 
whose  nervous  systems  have  undergone,  prior  to  injury,  the  deterioration 
due  to  absorption  of  alcohol.  I  have  not  been  convinced  by  my  experience, 
which  I  admit  to  be  somewhat  limited,  nor  by  my  reading  that  such  a 
concatenation  of  symptoms  can  occur  after  traumatism  in  the  absolutely 
abstemious.  The  amount  of  drinking  requisite  to  induce  the  predisposi- 
tion varies  with  the  individual.  The  repeated  ingestion  of  quite  small 
quantities  of  alcohol  may  give  rise  to  the  delirious  susceptibility.  It  is 
possible  that  a  similar  deterioration  of  constitution  and  consequent  lia- 
bility to  trembling  delirium  may  be  caused  by  the  opium,  chloral,  tobacco, 
and  other  similar  habits ;  but  it  is  difficult  to  differentiate  these,  because 
of  their  frequent  association  with  alcoholic  excess. 

Traumatic  delirium  tremens  may  follow  even  slight  injuries,  but  com- 
pound fractures  and  burns  seem  to  have  a  special  tendency  to  develop 
this  serious  complication.  Its  occurrence  should  not  be  ascribed  to  the 
restraint  imposed  upon  the  patient's  habits  by  the  injury,  but  to  a  trau- 
matic disturbance  of  a  previously  unstable  nervous  equilibrium.  The 
medical  authorities  vary  in  their  appreciation  of  the  causative  influence 
exerted  by  sudden  deprivation  of  accustomed  stimulants  in  exciting  attacks 
of  ordinary  delirium  tremens.  It  is  probable,  however,  that  in  a  vast 
majority  of  such  cases  the  directly  exciting  causes  are  the  deficient  assimi- 
lation of  food,  the  anxiety  and  the  nervous  strain  which  go  hand  in  hand 
with  a  period  of  debauch,  and  which  persist  after  the  ingestion  of  alcohol 
is  stopped.  Neither  is  the  recurrence  of  the  malady  to  be  imputed  to  the 
directly  poisonous  effect  of  a  large  amount  of  consumed  alcohol,  since 
acute  alcohol  poisoning  in  persons  unaccustomed  to  the  use  of  alcohol 
gives  rise  to  stupor  and  death,  but  not  to  delirium. 

Traumatic  delirium  tremens  occurs  because  obscure  chronic  changes  in 
the  nervous  tissue  or  blood,  or  perhaps  in  both,  have  rendered  the  alcohol 
drinker  susceptible  to  such  an  outbreak  upon  the  application  of  any  dis- 
turbing influence.  The  receipt  of  injury  is  a  sufficiently  perturbing 
force,  especially  if  the  patient  be  on  the  verge  of  an  idiopathic  attack.  It 
has  been  thought  that  the  use  of  beverages  containing  amylic  alcohol 
(fusel  oil),  especially  predisposes  to  delirium  tremens. 

Pathology.— The  alteration  in  nerve  structure  or  blood,  which  is  the 
essential  pathological  factor  of  delirium  tremens,  is  unknown  to  us.     An 


21G      DISEASES    AND    INJURIES    OF    NERVOUS    CENTRES. 

abnormal  amount  of  serum  is  usually  found  in  the  substance  and  within 
the  ventricles  of  the  brain,  meningeal  congestion  and  hemorrhage  are 
often  seen  ;  the  cells  of  the  gray  matter,  the  cerebral  connective  tissue, 
lym])h  spaces  and  vessels  show  sclerotic  or  fatty  changes,  and  the  liver, 
kidneys,  and  digestive  tract  exhibit  the  characteristic  lesions  found  in 
chronic  alcoholism,  but  there  is  nothing  to  which  we  can  point  as  the 
distinctive  lesion  of  delirium  tremens. 

Symptoms. — The  initiatory  symptoms  of  traumatic  delirium  tremens 
are  sleeplessness  at  night  and  slight  tremor,  which  is  readily  noticed  by 
ordering  the  patient  to  hold  out  the  hand  with  widely  distended  fingers. 
Subsequently  restlessness,  insomnia,  and  tremor  increase,  and  delirium  is 
shown. 

The  delirium,  which  is  often  first  exhibited  at  night,  is  peculiar.  The 
patient  sees  numerous  small  animals  or  insects  creeping  over  the  bed  and 
about  his  person,  or  is  pursued  by  some  hideous  spectre.  Hence,  he  is 
constantly  endeavoring  to  eject  the  vermin  from  his  clothing,  or  trying  to 
escape  the  persecutions  of  his  tormentor.  He  may,  in  his  efforts  to  get 
rid  of  these  disgusting  and  distressing  annoyances,  leave  his  bed  and  fall 
from  a  window  or  down  a  flight  of  steps.  The  mental  condition  is  one  of 
depression,  trepidation,  and  great  activity.  He  is  exceedingly  restless, 
and  is  constantly  chattering  in  a  low  tone ;  but  though  he  may  cry  out 
because  of  fear,  he  shows  little  or  no  maniacal  excitement.  He  is  good- 
natured,  not  prone  to  violence,  and  can  often  be  aroused  by  emphatically 
spoken  words  to  an  understanding  of  his  surroundings ;  but  he  soon  relapses 
into  the  previous  incessant  chattering  and  motion.  Very  often  a  single 
idea  recurs  again  and  again  to  his  delirious  fancy,  and  not  infrequently 
the  delirium  has  a  comical  or  tragico-comical  aspect.  The  muscular 
tremor  is  not  like  the  twitching  of  tendons  seen  in  asthenic  conditions,  but 
resembles  the  shakiness,  from  want  of  coordination,  seen  in  cerebro-spinal 
sclerosis.  Often  there  is  hurry  in  movement,  and  the  limbs  or  tongue 
will  then  be  thrust  forward  with  a  jerk.  The  tremor  of  delirium  tremens 
reminds  one  much  of  the  movements  that  would  be  expected  in  an  asso- 
ciation of  chorea  with  sclerosis  of  the  nervous  centres. 

During  these  symptoms  the  patient  is  unable  to  sleep,  is  incessantly  in 
motion,  and  has  a  bright  eye  with  dilated  puj)ils  and  an  unsteady,  rest- 
less look.  He  exhibits  a  moist,  flabby,  tremulous  tongue,  with  a  whitish 
fur  ;  desires  no  food ;  has  constipated  bowels,  and  passes  a  scanty,  high- 
colored  urine.  In  idiopathic  delirium  tremens  of  moderate  severity  there 
is  no  great  acceleration  of  the  pulse,  and  the  temperature  does  not  rise 
much  above  100°,  except  during  active  muscular  exertion.  In  those 
graver  cases,  which  Magnan  calls  febrile  delirium  tremens,  the  bodily 
heat  is  apt  to  remain  in  the  neighborhood  of  102°-105°,  though  there  is 
no  incurrent  affection  to  keep  up  the  temperature,  and  the  pulse  rate  is 
also  increased.  In  traumatic  delirium  tremens  the  constitutional  disturb- 
ance, due  to  the  wound,  affects  the  pulse  and  temperature.  The  patient 
will  often  remove  the  dressing  from  his  wound,  or  subject  the  injured 
limb  to  violent  motion  w'ithout  appearing  to  experience  pain. 

Traumatic  delirium  tremens,  as  a  rule,  arises  within  two  or  three  days 
after  the  receipt  of  injury  and  lasts  usually  not  more  than  five  or  six 
days.  The  illusions  are  apt  to  continue  during  the  night,  even  after  the 
patient  has  become  convalescent  and  quite  rational  in  tlie  daytime. 

Diagnosis. — The  peculiarity  of  tremor  and  delirium  renders  the  diag- 
nosis easy,  except  from  the  condition  called  above  nervous  or  asthenic 
traumatic  delirium.     The  existence  of  the  described  symptoms  is,  there- 


TEAUMATIC    DELIRIUM    TREMENS.  217 

fore,  not  absolute  evidence  of  previous  habits  of  stimulation,  since  it  is 
possible  that  great  nervous  strain  prior  to  injury  may  lead  to  a  similar 
delirium.  Usually,  however,  alcohol  seems  to  be  the  predisposing  cause, 
though  it  is  not  always  wise  to  mention  the  suspicion,  nor  to  call  the 
disease  delirium  tremens,  since  the  patient's  friends  may  be  unaware  of 
the  existence  of  such  habits. 

Prognosis. — Death  may  occur  from  exhaustion,  coma,  or  some  inter- 
current affection  ;  and  is  sometimes  inexplicably  sudden.  The  character 
of  the  traumatism  may  determine  the  mode  of  death.  Pneumonia  is  fre- 
quently associated  with  delirium  tremens.  It  is  often,  in  fact,  the  exist- 
ing cause  of  the  delirious  outbreak,  and,  of  course,  in  traumatic  cases 
greatly  diminishes  the  chances  of  recovery.  When  the  temperature  shows 
a  tendency  to  remain  high  without  a  sufficient  traumatic  cause,  and  espe- 
cially when  the  tremor  affects  all  the  muscles  of  the  trunk  as  well  as 
those  of  the  head  and  extremities  and  is  not  arrested  during  sleep,  the 
prognosis  is  bad. 

A  history  of  previous  attacks  of  the  disease  renders  the  outlook  more 
grave. 

Treatment. — It  is  important  to  bear  in  mind  that  delirium  tremens  is 
an  asthenic  condition.  There  is  action,  but  it  is  the  activity  of  weakness 
not  of  power.  Depressants  are,  therefore,  injurious.  Five  or  ten  grains 
of  calomel  or  one  or  two  Seidlitz  powders  may  be  administered  in  the 
beginning  of  the  disease,  or  when  its  occurrence  is  feared,  because  of  the 
anorexia  and  gastric  derangement. 

Concentrated  liquid  food  with  bitter  tonics  and  capsicum  add  to  the 
patient's  strength  and  tend  to  give  tone  to  the  impaired  digestive  organs  ; 
bathing,  Turkish  baths  if  possible,  and  mild  diuretics  may  be  prescribed 
in  the  endeavor  to  eliminate  the  alcohol  that  has  entered  the  system. 
Hydrate  of  chloral  (gr.  x-xx)  with  bromide  of  potassium  (gr.  xxx- 
xl)  should  be  given  every  two  or  three  hours  as  soon  as  sleeplessness  and 
slight  tremor  is  noticeable.  No  visitors  should  be  allowed  in  the  room. 
If  the  development  of  the  attack  is  not  prevented,  the  same  treatment  is 
continued,  but  the  dose  may  be  increased.  The  object  is  to  quiet  the 
nervous  system  and  produce  sleep.  In  this  endeavor  an  occasional  dose 
of  morphia  (gr.  ^-^)  may  be  combined  with  the  chloral  and  bromide  of 
potassium.  The  excessive  use  of  opiates  is  undesirable  for  it  is  not  nar- 
cotism that  is  desired,  but  sleep.  Cerebral  congestion  is  induced  by  over- 
dosing with  morphia.  If  fatty  heart  exists  opiates  should  be  pushed, 
perhaps,  rather  than  the  chloral  and  bromide  of  potassium.  The  com- 
bination treatment  by  the  three  hypnotics  allows  the  surgeon  to  diminish 
or  mcrease  each  element  according  to  indications.  Tincture  of  digitalis 
(TTi^x-TTLxxx)  is  valuable  in  cases  of  weak  but  not  fatty  heart,  where  there 
are  pallor  and  cyanosis  with  probable  ansemia  of  the  brain.  Strychnia  has 
been  recommended  in  delirium  tremens.  Hyoscine  hydrobromate  (gr. 
Y^)  and  other  hypnotics  may  prove  serviceable. 

Mechanical  restraint  with  straps  and  the  straight-jacket  is  only  to  be 
adopted  when  efiicient  watching  and  soothing  by  attendants  are  imprac- 
ticable. All  such  apparatus  excites  the  patient  and  is  very  liable  to  in- 
terfere with  respiration.  The  best  appliance  is  a  loose,  but  strong,  gar- 
ment consisting  of  trousers  and  shirt  in  one  piece,  with  loops  attached  for 
fastening  the  patient  in  bed.  Fractures  should  be  dressed  with  plaster- 
of  Paris  bandages,  because  ordinary  splints  will  probably  be  displaced  by 
the  patient.  If  failure  of  vital  powers  is  to  be  feared,  alcoholic  stimu- 
lants in  small  amounts,  administered  only  when  food  is  given,  are  judi- 


218      DISEASES    AND    INJURIES    OF    NERVOUS    CENTRES. 

cioiis,  because  in  chronic  drinkers  digestion  will  sometimes  not  go  on 
efficiently  without  the  aid  of  alcohol.  The  failure  of  assimilation  in 
delirium  tremens  may  turn  the  scale  against  the  patient.  Whiskey  or 
brandy  (f.^ij  to  f.^iv  daily)  in  the  form  of  milk  punch  or  eggnog  is 
probal)ly  the  best  form  of  administration.  Many  patients  will  not  require 
any  stimulants  whatever. 

Vomiting  occurring  in  delirium  tremens  is  to  be  treated  by  milk  and 
lime  water,  cracked  ice,  efiervesciug  drinks,  subnitrate  of  bismuth,  pep- 
sin, and  carbolic  acid  mixtures. 

Nervous  traumatic  delirium  is  to  be  treated  by  bromides,  chloral,  hyos- 
cine,  and  nerve  tonics,  and  presents  a  favorable  prognosis. 

Septic  or  inflammatory  traumatic  fever  requires  judicious  antiseptic 
treatment  to  combat  the  local  infection  with  septic  products ;  cold  to  the 
head  and  hypnotic  remedies.  It  occurs  when  the  septic  fever  is  at  its 
height  and  is  often  more  conspicuous  at  night ;  resembling  in  this  latter 
respect  alcoholic  traumatic  delirium. 


CHAPTEE    XYI. 

DISEASES  AND  INJURIES  OF  THE  HEART  AXD  BLOODVESSELS. 

DISEASES    AXD    INJURIES    OF    THE    HEART    AND    PERICARDIUM. 

Wounds  of  the  Pericardium  and  Heart. 

Punctures  and  small  incisions  of  the  pericardium,  if  uncomplicated  with 
injury  to  the  internal  mammary  artery,  heart,  or  lungs,  present  no  marked 
symptoms,  and  are  usually  soon  repaired  by  a  local  pericarditis.  Such 
wounds  are  made  almost  Avith  impunity  in  treating  pericardial  effusions 
by  aspirations  and  incision. 

Larger  wounds  are  much  more  serious  by  reason  of  the  suppuration 
that  is  liable  to  occur  and  the  involvement  of  neighboring  structures. 
The  treatment  of  pericardial  wounds  consists  in  rest,  antiseptic  dressings, 
and,  if  suppuration  takes  place,  free  exit  for  the  pus  by  incision,  drainage 
and  frequent  irrigation.  If  pericardial  eftlision  occurs  after  a  contusion 
or  laceration  of  the  membrane,  blisters,  diuretics,  and  hydragogues  should 
be  employed  as  in  rheumatic  pericarditis.  If  the  effusion  persists  and 
the  symptoms  become  urgent,  pericardicentesis  should  be  performed. 

Wounds  of  the  heart  are  generally,  but  not  necessarily,  fatal.  Patients 
have  survived  many  years  with  foreign  bodies  buried  in  the  cardiac  walls. 
The  diagnosis  is  obscure,  though  signs  of  internal  hemorrhage,  or  profuse 
external  bleeding  with  syncope,  or  great  shock,  with  irregular  and  feeble 
action  of  the  heart  occurring  after  a  wound  of  the  pericardium  make  it 
probable  that  the  heart  has  been  injured. 

Small  cardiac  wounds  may  not  be  followed  by  much  bleeding,  because 
the  peculiar  interlacing  of  the  muscular  fibres  causes  the  opening  to  be 
closed  as  by  a  valve.  In  other  cases  the  pericardium  may  become  filled 
with  blood  to  such  an  extent  as  to  make  the  cardiac  sounds  and  beat 
almost  imperceptible.  Death  may  arise  from  interference  with  the  heart's 
action  in  this  manner  when  the  wound  itself  is  not  necessarily  fatal.  The 
hemorrhage  from  the  heart  may  be  slow  or  be  arrested  by  a  clot  forming 
in  the  orifice.  This  may  be  washed  out  when  reaction  from  shock  occurs 
and  secondary  hemorrhage  and  death  thus  take  place.  Men  may  even 
walk  after  wound  of  the  heart.  Dyspnoea,  pain,  pericardial  distress,  and 
a  systolic-bellows  sound  have  been  observed  in  heart  wounds,  but  these 
symptoms  and  signs  are  not  always  present. 

It  should  be  remembered  that  the  heart  lies  obliquely  between  the  upjDcr 
margin  of  the  third  costal  cartilage  and  the  top  of  the  sixth  cartilage,  and 
that  it  extends  from  a  line  about  one  inch  inside  of  the  ieft  nipple  to  a 
point  a  little  beyond  the  right  margin  of  the  sternum.  Wounds  of  the 
auricles  are  more  dangerous  than  similar  injuries  to  the  ventricles. 

Wounds  of  the  heart  must  be  treated  by  absolute  rest  in  the  supine 
position,  by  cold  to  the  front  of  the  chest,  morphia,  atropia,  and  digatalis. 
W^hen  it  is  certain  that  clots  in  the  pericardium  are  doing  harm,  incision 
of  that  sac,  removal  of  the  clots,  and  antisei^tic  injections  may  be  advan- 


220  DISEASES    AXJ>    INJURIES   OF    HEART. 

tageous.  Experimental  suture  of  the  heart  hiv<  been  done  successfully,  it 
is  said,  in  the  lower  animals.  I  should  not  hesitate  to  open  the  pericar- 
dium and  attempt  to  suture  a  heart-wound  in  the  human  subject,  if  evi- 
dence of  such  a  wound  was  strong.  Resection  of  the  costal  cartilages 
might  be  necessary  in  order  to  gain  access  to  the  parts. 


Tapping  the  Pericardium  or  Pericardiceiitesis. 

In  pericarditis  with  effusion,  and  in  cases  of  hydropericardium  from 
renal  disease,  the  pressure  exerted  upon  the  heart  by  the  accumulated 
fluid  is  at  times  a  mechanical  cause  of  death.  Hence,  it  may  become 
necessary  to  withdraw  the  fluid  by  aspiration.  In  all  cases  of  pericardial 
eflusion  which  present  dangerous  symptoms  of  heart  failure,  aspiration 
should  be  performed  as  soon  as  it  is  evident  that  medication  is  not  lessen- 
ing the  embarrassment  of  the  central  organ  of  circulation.  It  is  bad  prac- 
tice to  delay  operation  until  exhaustion,  pulmonary  engorgement,  and 
degeneration  of  the  cardiac  muscle  render  permanent  relief  impossible.  A 
moderate  quantity  of  serum  suddenly  effused  will  exert  more  pressure  on 
the  heart  than  a  much  larger  amount  poured  out  in  so  gradual  a  manner 
as  to  allow  the  pericardium  to  become  stretched.  Hence,  the  symptoms, 
and  not  the  amount  of  serum,  must  be  the  guide  to  operation. 

If  there  coexists  pleural  effusion  of  considerable  amount,  the  pleural 
sac  should  be  aspirated  flrst,  because  it  is  difficult  to  discriminate  between 
respiratory  distress  due  to  pulmonary  pressure  and  that  resulting  second- 
arily from  interference  with  cardiac  action.  This  rule  applies  to  pleurisy 
of  the  right  side  as  well  as  of  the  left. 

AVhen  the  amelioration  of  symptoms  following  pericardial  aspiration  is 
not  permanent,  because  reaccumulation  takes  place,  the  operation  should 
be  repeated.  It  is  better  to  vary  the  point  of  puncture,  lest,  on  account 
of  adhesion  of  the  layers  of  pericardium  at  the  original  point,  the  heart 
be  wounded  at  the  second  taj^piug.  .Should  repeated  tapping  be  demanded, 
I  should  be  inclined,  after  the  third  operation,  to  inject  some  irritating 
fluid,  such  as  tincture  of  iodine,  into  the  sac,  with  the  idea  of  producing 
adhesion  of  the  two  layers  of  pericardium. 

When  aspiration  has  shown  the  pericarditis  to  be  distinctly  purulent, 
it  is  practically  certain  that  repetition  of  the  operation  will  be  demanded. 
In  such  an  event  the  introduction  and  retention  of  an  antiseptic  rubber 
drainage-tube,  after  a  free  incision  has  been  made,  strike  me  as  the  most 
judicious  kind  of  surgery.  The  cavity  can  be  washed  out  daily  with  anti- 
septic solutions,  and  purulent  accumulation  with  its  attendant  dangers  of 
pressure  on  the  heart  and  septicjemia  avoided. 

Incision  may  be  useful  in  certain  cases  as  a  diagnotic  procedure,  when 
doubt  exists  as  to  the  condition  being  dilated  heart  or  pericardial  eflfusion. 

The  best  point  for  aspiration'  of  the  pericardium  is  in  the  fifth  inter- 
space, just  above  the  sixth  rib,  about  five  or  six  centimetres  (2-2^  inches) 
to  the  left  of  the  median  line  of  the  sternum.  In  a  child  it  should  be 
nearer  the  sternum.  The  ordinary  aspirating  needle  or  the  aspirating 
trocar  which  I  have  devised  may  be  employed.  In  all  cases  the  vacuum 
chamber  should  be  attached  to  the  puncturing  instrument  as  soon  as  its 
point  is  buried  beneath  the  skin,  in  order  that  the  flow  of  fluid  may  indi- 
cate the  moment  when  the  pericardium  is  entered. 

1  Paracentesis  of  the  Pericardium,  by  John  B.  Roberts.     Philadelphia,  1880. 


HEMORRHAGE.  "    -l21 

The  pericardial  aspirating  trocar  recommended  consists  of  a  moderate 
size  aspirating  needle,  within  which  slides  a  canula  with  a  flexible  end. 
During  penetration  of  the  chest  wall  the  canula  is  retracted,  so  that  the 

Fig.  81. 


Roberts's  aspirating  pericardial  trocar. 

flexible  end  is  contained  within  the  needle.  Afterward  it  is  thrust  for- 
ward to  guard  the  sharp  point  of  the  needle  and  prevent  scratching  of 
the  heart's  surface  when  withdrawal  of  the  fluid  causes  the  pericardial 
sac  to  collapse. 

Diseases  and  Injuries  of  the  Arteries,  Veins,  and  Capillaries. 

Hemorrhage. 

Definition. — An  escape  of  blood  from  the  vessels  is  called  hemor- 
rhage, and  is  either  sjjontaneous  or  traumatic.  When  the  blood  is  dis- 
charged, not  upon  the  surface  of  the  body  or  into  a  cavity,  but  into  the 
meshes  of  the  connective  tissue,  the  term  extravasation  is  generally  used. 
An  extravasation  into  the  connective  tissue  beneath  the  skin  is  often 
designated  a  subcutaneous  hemorrhage. 

Varieties. — Traumatic  hemorrhage  is  primary  when  it  immediately 
follows  the  receipt  of  wound  ;  intermediary  when  it  occurs  after  reaction 
from  the  shock  of  injury,  and  before  the  lapse  of  twenty-four  hours ;  and 
secondary,  when  it  takes  place  between  the  end  of  the  flrst  twenty-four 
hours  and  the  completion  of  cicatrization  of  the  wound. 

Intermediary,  often  called  recurring,  hemorrhage  arises  because  the 
force  of  the  circulation  has,  from  the  establishment  of  reaction,  become 
sufilcient  to  displace  the  clots  which,  during  the  previous  condition  of 
feeble  circulation,  prevented  bleeding. 

It  may,  therefore,  occur  from  small  vessels  that  did  not,  at  the  time 
the  wound  was  dressed,  seem  to  demand  ligatures  or  other  treatment ;  or 
from  larger  ones  to  which  ligation,  torsion,  or  acupressure  was  carelessly 
or  imperfectly  applied,  or  in  which  the  wound  was  so  small  that  no  hemor- 
rhage supervened  until  the  circulation  had  fully  regained  its  force. 

Secondary  hemorrhage  may  be  due  to  any  constitutional  condition, 
such  as  hematophilia,  septicaemia,  pyaemia,  hepatic  disease,  and  renal  dis- 
ease, which  interferes  with  the  plastic  changes  and  organization  of  the 
internal  clot  that  constitute  Nature's  method  of  permanently  sealing 
wounded  vessels.  Hence,  when  the  ligature  is  absorbed,  or  the  wail  of 
the  vessel  ulcerated  through  at  the  point  of  ligation,  bleeding  supervenes. 

Secondary  bleeding  may  also  be  caused  by  an  unrecognized  contusion 
or  abrasion  of  the  vessel  wall  which  has  subsequently  given  away  at  the 
injured  spot,  by  failure  of  the  surgeon  to  secure  the  distal  end  of  the 
artery  or  to  tie  a  wounded  branch  situated  just  above  the  ligature.  In 
the  last  two  instances  the  establishment  of  the  anastomotic  circulation 
may  be  followed  by  bleeding.  Sloughing  in  the  wound,  atheroma  of  the 
arterial  wall,  septic  processes  due  to  septic  ligatures  or  dressings,  badly 
applied  ligatures,  premature  softening  of  a  ligature,  and  the  rush  of  the 


222  DISEASES    AND    INJURIES    OF    BLOODVESSELS. 

blood-current  through  ii  large  branch  given  off"  just  above  the  point  of 
ligation  are  frequent  cause  of  secondary  hemorrhage.  Secondary  bleeding 
usually  does  not  occur  earlier  tlian  one  week,  or  later  than  three  weeks 
after  the  time  of  injury  or  operation.  Septic  causes  are  res[)onsible  for  the 
majority  of  cases  of  secondary  hemorrhage.  Aseptic  surgery  has  almost 
made  secondary  hemorrhage  unknown.  This  serious  complication  must, 
therefore,  be  carefully  proviiled  for  about  the  fourteenth  day,  especially 
after  ligation  of  arteries  in  continuity  for  aneurism.  In  such  cases  the 
secondary  hemorrhage  is  more  apt  to  occur  at  the  distal  than  the  cardiac 
side  of  the  ligature,  because  internal  coagulation  and  cellular  changes 
occurring  there  are  less  effective  than  in  the  [)roximal  or  cardiac  portion 
of  the  artery,  and  ])robably,  also,  because  the  ligature  interferes  with  the 
small  vessels  supplying  the  arterial  coats  below  the  seat  of  constriction. 
The  rapid  healing  of  wounds  under  aseptic  and  antiseptic  treatment  has 
made  secondary  hemorrhage  much  less  frequent  than  formerly. 

The  occurrence  of  profuse  secondary  bleeding  is  generally  preceded  by 
a  slight  flow  of  blood,  which,  when  observed  during  the  progress  of  cica- 
trization or  suj)puration,  should  always  be  looked  upon  as  a  warning  of 
grave  import.  There  may  be  several  slight  hemorrhages  from  the  wound, 
and  then,  when  the  surgeon  flatters  himself  that  he  has  nothing  further 
to  fear,  a  profuse  bleeding  quickly  destroys  the  enfeebled  and  anaemic 
patient.  The  treatment  of  secondary  hemorrhage  is  of  exceeding  impor- 
tance, and  will  be  considered  after  the  discussion  of  the  treatment  of  pri- 
mary bleeding. 

IJlood  starts  from  a  wounded  artery  in  a  rapid  stream,  and,  as  each 
beat  of  the  heart  gives  an  increased  impulse  to  the  blood-current,  the  jet 
gains  force,  and  is  propelled  further  synchronously  with  the  cardiac  pul- 
sations. The  blood  is  of  a  bright-red  color,  unless  the  patient  is  deeply 
anaesthetized  or  partially  asphyxiated ;  then  respiration  and  oxygenation 
are  imperfectly  performed,  and  the  blood  is  dark.  When  an  artery  has 
been  completely  divided,  the  hemorrhage  from  the  end  further  from  the 
heart  may  not  be  rhythmical  until  the  collateral  circulation  is  well  estab- 
lished. 

Venous  hemorrhage  is  characterized  by  a  steady  flow  of  dark  blood, 
which  is  not  aflected  by  the  heart's  action.  The  stream  may  show  a  ten- 
dency to  rise  and  fall  in  a  sluggish  manner  with  each  respiratory  act,  but 
never  spurts.  If  the  bleeding  occurs  at  the  bottom  of  the  wound  the 
blood  may  become  reddish  from  admixture  with  air  before  it  reaches  the 
surface. 

Hemorrhage  from  capillary  vessels,  called  parenchymatous  hemor- 
rhage, occurs  as  an  oozing  of  blood.  The  steady  stream  has  a  color  less 
red  than  arterial  and  less  purple  than  venous  blood. 

Causes. — Solution  of  continuity  of  vascular  walls  is  the  common  cause 
of  hemorrhage,  but  bleeding  does  occur  at  tiuies  from  mucous  and  serous 
surfaces  without  apparent  lesion.  Here  the  quality  of  the  blood  is  prob- 
ably at  fault.  Cirrhosis  of  the  liver  and  poisoning  by  phosphorus  and 
some  other  substances  are  said  to  cause  this  form  of  blood  transpiration. 
It  must  be  recollected  that  hemorrhage  from  any  part  may  be  vicarious 
to  menstruation  or  other  customary  loss  of  blood. 

Constitutional  Effects  of  Hemorrhage. — It  is  exceedingly  im- 
portant that  the  surgeon  should  recognize  the  general  symptoms  of  hemor- 
rhage. In  certain  cases  no  blood  is  visible  externally,  though  a  sufficient 
quantity  to  cause  fatal  anremia  has  been  poured  out  into  the  intestines, 
uterus,  or  abdominal  cavity ;  or  into  the  cellular  tissue  surrounding  the 


HEMOERHAGE.  223 

perforated  vessel.  Such  concealed  hemorrhages  are  to  be  recognized  by 
the  constitutional  effects  produced  by  the  withdrawal  of  blood  from  the 
vascular  channels. 

The  general  symptoms  of  hemorrhage  are  influenced  by  the  constitu- 
tional characteristics  of  the  patient  and  the  vessel  from  which  the  blood 
flows,  but  depend  more  especially  upon  the  quantity  of  blood  lost  and  the 
rapidity  of  its  escape.  An  insignificant  bleeding  may  prostrate  even  to 
syncope  a  debilitated  or  frightened  subject,  while  a  considerable  hemor- 
rhage will  in  some  others  give  rise  to  no  prominent  symptoms.  Children 
and  the  aged  are  very  impressible  by  loss  of  blood.  Arterial  hemorrhage 
may  be  expected  to  produce  greater  depression  than  a  similar  loss  from 
veins,  for  the  obvious  reason  that  venous  blood  is,  in  a  certain  degree,  an 
effete  fluid. 

When  a  violent  and  profuse  gush  of  blood  occurs  from  rupture  of  a 
large  arterial  trunk,  death  is  rapid.  The  blood  in  all  the  arteries  has  a 
recurrent  tendency,  and,  instead  of  being  forced  by  arterial  and  cardiac 
contraction  into  the  peripheral  vessels,  it  flows  toward  the  w^ound  ;  hence 
there  is  a  consequent  venous  stagnation  which  gives  a  livid  tinge  to  the 
otherwise  pallid  surface.  The  patient,  who  has  fallen  to  the  ground  in  a 
state  of  syncope,  gasps  for  breath,  throws  his  limbs  about  restlessly,  and, 
after  convulsive  twitchings  of  the  facial  and  other  muscles,  expires. 
Profuse  hemorrhage  from  a  large  venous  trunk  causes  death  in  a  some- 
what similar  manner.  A  less  impetuous  loss  of  blood,  whether  arterial 
or  venous,  causes  a  feeble  and  rapid  pulse,  sighing  respiration,  pale  con- 
junctivfe  and  lips,  a  cold  clammy  skin,  dilated  pupils,  restlessness,  and  a 
confused  mind.  The  patient  feels  weak  and  thirsty,  is  giddy,  has  im- 
paired vision  and  hearing,  or,  perhaps,  sees  luminous  spots  or  hears 
unusual  noises,  experiences  a  sense  of  suffocation,  but  feels  no  special 
pain,  and  rather  suddenly  loses  consciousness.  During  this  state  of  syn- 
cope the  breathing  is  almost  entirely  diaphragmatic,  and  the  heart's 
pulsation  can  scarcely  be  detected.  This  lowering  of  circulatory  tension 
gives  an  opportunity  for  coagulation  in  the  wounded  vessel,  and  the  bleed- 
ing is  arrested.  The  patient  now  recovers  from  the  condition  of  insensi- 
bility, and,  perhaps,  vomits  as  he  returns  to  consciousness.  The  increasing 
force  of  the  heart's  action,  however,  is  soon  sufiicient  to  cause  the  blood- 
current  to  force  the  clot  from  the  interior  of  the  injured  bloodvessel,  and 
hemorrhage,  with  the  train  of  symptoms  mentioned  above,  recurs.  This 
alternation  of  bleeding  and  spontaneous  arrest  is  kept  up  until  death 
occurs  from  ansemia  of  the  nervous  centres.  Sometimes  delirium,  con- 
vulsions, and  hemiplegia  precede  the  fatal  termination.  In  very  slow 
hemorrhage  there  arises  great  debility,  with  waxy-looking  skin,  oedema  of 
the  dependent  parts,  and  a  tendency  to  syncope  on  assuming  the  erect 
posture. 

After  death  from  prolonged  or  repeated  hemorrhage  the  tissues  are 
soft  and  flabby,  because  the  fluids  have  been  absorbed  to  fill  the  emptied 
bloodvessels.  This  explains,  also,  the  thirst  felt  by  the  patient.  After 
serious  hemorrhages  have  been  stopped  a  stage  of  reaction  often  supervenes, 
to  which  the  name  hemorrhagic  fever  has  been  applied.  The  symptoms  are 
febrile  manifestations  and  a  frequent,  quick  pulse,  accompanied  by  irrita- 
bility and  restlessness  of  mind  and  body.  Occasionally  hemorrhage  is 
followed  by  a  chronic  ansemia,  which  is  extremely  rebellious  to  treatment. 
The  febrile  state,  above  mentioned,  is  to  be  met  by  rest,  sponging  the 
surface,  cold  to  the  head,  nutritious  fluid  food,  and  tonic  remedies. 


224  DISEASES    AND    INJURIES    OP^    BLOODVESSELS. 

Nature's  ]\[oi)e  of  Arresting  Hemorrha(;e. — Obscure  is  the 
nieaus  by  which  spontaneous  cessation  of  hemorrhage  is  determined  in 
those  unusual  cases  of  oozing,  without  apparent  lesion  of  the  bleeding 
surface,  which  have  l)eeu  mentioned. 

Hemorrhage,  from  vessels  in  whose  walls  a  solution  of  continuity  has 
been  produced  by  accident  or  operation,  often  ceases  spontaneously.  It 
usually  does  so  in  veins,  except  those  of  great  calibre,  and  in  arteries 
smaller  than  the  radial  anil  facial.  The  method  employed  by  Nature  in 
arresting  hemorrhage  is  the  same  in  arteries  and  veins,  though  in  the 
latter  the  sluggish  blood-current  does  not  demand  such  active  contraction 
and  retraction  of  the  walls  of  the  vessel. 

When  an  artery  has  been  completely  divided.  Nature  promptly  insti- 
tutes steps,  which  are  intended  to  cause  a  temporary  arrest  of  the  escape 
of  blood  until  a  permanent  occlusion  of  the  open  extremity  can  be 
accomplished.  The  same  series  of  changes  occur  in  both  the  cardiac  and 
distal  ends  of  the  cut  vessel.  The  temporary  means  consist  of:  (1)  Con- 
traction and  retraction  of  the  cut  end  ;  and  (2)  clotting  of  the  escaping 
blood  in  and  around  the  sheath  of  the  vessel. 

The  permanent  means  are:  (1)  The  formation  of  a  clot  within  the 
artery  ;  (2)  plugging  of  the  orifice  and  union  of  the  edges  of  the  cut 
extremity  by  the  ordinary  process  of  repair;  and  (8)  cicatricial  contrac- 
tion of  the  walls  of  the  vessel  by  which  an  impervious  fibrous  cord  is 
produced. 

Temporary  ]Means. — The  contraction  of  the  walls  of  the  vessel, 
which  extends  up  to  the  first  branch,  gives  its  section  a  flattened  or  ovoid 
shape,  and,  by  diminishing  the  calibre,  lessens  the  size  of  the  blood- 
stream. At  the  same  time,  the  retraction  of  the  cut  end  of  the  artery 
within  the  sheath  leaves  a  space  between  it  and  the  wound  in  the  non- 
retractile  sheath,  which  detains  the  escaping  blood  and  encourages 
coagulation.  Coagulation  also  takes  place  outside  of  the  wounded 
sheath.  Lacerated  vessels,  by  the  irregularities  of  the  torn  ends  and  of 
the  sheath,  encourage  this  clotting,  and  may  even,  if  large,  soon  stop 
bleeding. 

Fig.  82. 

clot  in  sheath 
;ath 


CONTRACTED  AWD  RETRACTED 
ARTERY 

Diagram  of  Nature's  temporary  method  of  arresting  hemorrhage. 

These  provisions  of  Nature  may  at  first  fail  to  stanch  the  bleeding, 
because  the  force  of  the  heart  is  suflficient  to  drive  enough  blood  through 
the  contracted  vessels  to  wash  away  the  intra-  and  extra-vascular  clots. 
As  the  continuing  hemorrhage  increases  the  coagulability  of  the  blood 
and  weakens  the  cardiac  power,  perhaps  to  syncope,  the  time  arrives 
when  these  temporary  expedients  of  Nature  stop  the  flow.  Cardiac 
strength  then  returns  and  may,  by  the  increased  intravascular  pressure, 
cause  recurrence  of  the  bleeding.     In  many  instances,  however,  the  tern- 


HEMORRHAGE.  225 

porary  means  are  effective  until  permanent  changes  can  be  brought  about 
to  repair  the  vascular  traumatism. 

Permanent  Means. — When  a  temporary  check  has  been  given  to  the 
flow  of  blood,  a  coagulum  gradually  forms  within  the  artery.  This  is 
conical  in  shape,  with  its  base  situated  and  fixed  at  the  opening,  while  its 
apex,  lying  loose  in  the  lumen  of  the  artery,  extends  as  high  as  the  first 
branch.  The  base  of  this  internal  clot  corresponds  in  size  with  the  in- 
terior of  the  vessel,  which  it  fits  like  a  cork. 

Fig.  83. 


INTERNAL  CLOT 

Diagram  of  internal  clot  formed  in  Nature's  method  for  the  permanent  arrest  of 

hemorrhage. 

After  the  deposition  of  this  internal  coagulum,  and  sometimes  without 
its  formation,  for  it  may  occasionally  be  absent,  an  exudation  of  inflam- 
matory lymph  occurs  in  the  stump  of  the  artery  and  around  it  and  the 
sheath.  This  plastic  material  unites  the  edges  of  the  wound  and  seals  the 
orifice  by  a  button-like  plug  of  exudate.  The  internal  blood  coagulum  is 
at  its  base  more  or  less  intimately  associated  and  commingled  with  the 
plastic  deposit.  Organization  of  the  exudate,  disappearance  of  the  blood- 
clot,  and  permanent  cicatricial  contraction  of  the  vessel  to  the  first  im- 
portant collateral  branch  go  on  until  finally  from  the  first  branch  above 
nothing  remains  but  an  impervious  fibrous  cord. 

Hemorrhage  from  a  wound  partially  dividing  an  artery  is  controlled  in 
a  similar  but  not  identical  manner.  Contraction  and  retraction  of  the 
vessel  cannot  occur  ;  but  blood  is  effused  within  and  around  the  sheath 
and  thus,  unless  it  rapidly  escapes  to  the  exterior  of  the  body,  causes 
pressure  upon  the  wounded  artery.  This  causes  temporary  arrest  of  the 
blood  escape.  An  internal  coagulum  may  then  be  formed.  Lymph  is 
subsequently  effused,  the  cavity  of  the  vessel  is  occluded,  and  fibrous 
metamorphosis  with  obliteration  of  the  vascular  channel  is  permanent. 
When  the  wound  is  less  in  extent  than  one-fourth  the  circumference  of 
the  vessel,  or  if  it  is  longitudinal  and  consequently  gapes  very  little, 
hemorrhage  may  cease  and  repair  occur  by  plastic  exudation,  without 
much  encroachment  upon  the  lumen  of  the  vessel.  In  such  cases,  how- 
ever, the  internal  and  middle  coats  are  seldom  firmly  united,  and  the 
force  of  the  circulatory  current  is  very  apt  eventually  to  cause  stretching 
of  these  tunics.     Thus  may  arise  traumatic  aneurism. 

Collateral  Circulation. — When  the  passage  of  blood  through  an 
artery  is  arrested  by  division,  ligation,  or  any  form  of  obstruction,  the 
parts  beyond  receive,  at  first,  less  blood.  As  a  consequence,  absence  of 
pulsation,  lowered  surface  temperature,  and  impaired  muscular  power  re- 
sult. Soon,  however,  the  anastomosing  branches  and  capillaries  of  the 
same  and  of  the  neighboring  arteries  dilate  by  a  vital  process  and  carry 
more  blood  to  the  part  than  is  normal.     This  is  shown  by  increased  red- 

15 


22f) 


DISEASES    AND    INJURIES    OF    BLOODVESSELS. 


uess  and  unnatural  elevation  of  temperature,  wliidi,  in  the  case  of  ob- 
struction of  large  arteries,  only  occurs  after  the  lai)se  of  many  hours. 
After  a  time  the  duty  of  supplying  the  distal  region  becomes  relegated  to 
a  few  branches,  which  remain  permanently  enlarged.  The  functions  of 
the  part  are  then  carried  on  exactly  as  they  were  previous  to  interference 
with  the  blood-supply. 

Fig.  84. 


,^ 


Collateral  circulation  after  wound  of  arterr  and  liijation. 


The  establishment  of  the  collateral  circulation  necessitates  a  reversal  of 
the  blood-current  in  some  vessels,  but  this  is  not  opposed  to  physiological 
processes.  In  aged  subjects,  whose  vessels  are  apt  to  be  rigid  and 
atheromatous,  dilatation  of  the  arteries  and  capillaries  cannot  always  be 
rapidly  and  readily  effected.  Hence,  in  such  subjects  gangrene  of  the 
peripheral  region  from  deprivation  of  blood  is  more  frequent  than  in  the 
young.  The  collateral  circulation  is  usually  efiected  by  the  anastomosis 
of  the  branches  on  the  same  side  of  the  body  and  not  by  inosculation 
with  branches  coming  from  vessels  across  the  median  line.  Thus,  when 
the  right  common  carotid  artery  is  ligated,  the  exterior  of  the  head  is 
supplied  by  the  inferior  thyroid,  a  sub-branch  of  the  subclavian,  furnish- 
ing blood  to  the  ramifications  of  the  superior  thyroid,  a  branch  of  the 
external  carotid.  The  current  in  the  superior  thyroid  is  reversed,  and 
the  blood  emptied  into  the  external  carotid,  which  carries  it  to  the  face 
and  scalp.  The  interior  of  the  head  is  nourished  by  the  vertebral,  a 
secondary  branch  of  the  subclavian,  communicating  within  the  skull  with 
the  cerebral  branches  of  the  internal  carotid.  Little  dilatation  occurs  in 
the  branches  inosculating  with  the  corresponding  vessels  of  the  left  side. 


HEMOEEHAQE.  227 

When  a  vein  is  obstructed  collateral  circulation  is  readily  established 
in  a  similar  way.  If  thei'e  is  failure  in  effecting  this  result,  venous  con- 
gestion and  oedema  occur  in  the  parts  below,  and  may  be  the  cause  of 
moist  gangrene. 

Hemorrhagic  Diathesis. — In  some  persons  a  peculiar  constitutional 
tendency,  often  inherited,  causes  profuse  and  almost  uncontrollable  bleed- 
ing from  slight  wounds,  such  as  simple  punctures  and  tooth-extraction. 
Spontaneous  hemorrhage  from  the  nostrils,  kidneys,  intestines,  or  bron- 
chial tubes,  and  large  extravasations  into  the  cellular  tissue  after  bruises, 
may  occur  in  such  subjects.  Hemorrhagic  diathesis  or  hematophilia  is 
usually  exhibited  in  childhood,  and  is  frequently  unknown  until  a  trivial 
injury  discloses  its  existence,  for  such  patients  often  enjoy  vigorous  health. 
A  liability  to  joint  affections  similar  to  rheumatism,  and  to  inflammations 
of  the  lungs,  has  been  said  to  coexist  with  the  hemorrhagic  diathesis. 
As  age  advances  the  bleeding  tendency  may  disappear.  In  some  instances 
there  are  attacks  of  spontaneous  hemorrhage,  though  wounds  may  be  in- 
flicted with  imjDunity  in  the  intervals. 

Males  are  much  more  frequent  subjects  of  hematophilia  than  females. 
The  cause  of  the  condition  is  unknown.  There  at  times  appear  to  be  de- 
ficient coagulability  of  the  blood,  and  unusual  thinness  of  the  internal 
coat  of  the  vessels. 

The  tendency  to  hemorrhage  is  to  be  combated  by  saline  laxatives, 
iron,  ergot,  lead,  and  opium.  Quinine  in  large  doses  has  been  recom- 
mended. All  operations  are  to  be  avoided.  If  wounds  occur  and  bleed, 
pressure  by  bandage,  ligature,  or  acupressure  must  be  employed.  The 
actual  cautery  is  a  valuable  local  agent. 

Treatment  of  Hemorrhage.  Constitutional .  Measures. — Before 
referring  to  the  local  means  of  checking  hemorrhage,  the  constitutional 
or  general  measures  must  be  mentioned;  though  they  are  much  less  im- 
portant. It  is,  in  fact,  only  after  the  bleeding  vessels  have  been  con- 
trolled, or  when  hemoirhage  is  feared,  but  has  not  yet  occurred,  that 
general  measures  obtain  much  consideration.  The  patient  should  be  kept 
quiet  and  recumbent,  with  the  head  low,  in  order  to  lessen  the  activity  of 
the  heart  and  prevent  anaemia  of  the  brain.  Sudden  deviation  of  the 
head  may  be  followed  by  fatal  syncope  when  much  blood  has  previously 
been  lost. 

The  supply  of  blood  to  the  nerve-centres  can  be  kept  up,  in  those  who 
have  suffered  collapse  from  profuse  hemorrhage,  by  encircling  the  four 
limbs  with  rubber  bandages,  as  in  the  bloodless  method  of  operating. 
This  drives  the  entire  volume  of  blood  to  the  head  and  trunk.  The 
elastic  pressure  can  be  continued,  as  we  know  from  experience  in  oj^era- 
tions,  for  at  least  an  hour  without  harm  to  the  extremities  thus  deprived 
of  blood.  If  several  limbs  are  bandaged,  it  is  well  to  remove  the  pres- 
sure slowly  and  from  one  at  a  time ;  lest  the  sudden  rush  of  blood  into 
the  limbs  cause  recurrent  ansemia  of  the  brain.  This  process  is  called 
auto-transfusion,  because  the  patient  has  his  own  blood  forced  into  the 
centres  of  organic  life.  If  rubber  bandages  are  not  at  hand,  flannel  or 
muslin  bandages  may  be  used ;  or  digital  compression  of  the  abdominal 
aorta  or  of  the  subclavian  and  axillary  arteries  will  prevent  the  exit  of 
blood  to  the  limbs,  and  thus  leave  more  for  distribution  to  the  head  and 
trunk. 

Morphia,  quinine,  ergot,  gallic  acid,  lead  and  iron,  in  full  doses,  have 
been  recommended  as  internal  hemostatic  remedies,  but  I  have  little  faith 


228  DISEASES    AND    INJURIES    OF    BLOODVESSELS. 

in  them  in  surgical  hemorrhages.     The  local  treatment  is  far  more  impor- 
tant and  effective. 

In  order  to  diminish  arterial  tension  and  thus  hasten  the  arrest  of  blood, 
Detmold  lias  suirgested  temporary  withdrawal  from  the  general  circula- 
tion of  some  of  the  blood.  This  is  ac(.'omj)Ushed  by  applying  bandages 
around  the  upper  arms  and  thighs  with  firmness  sufficient  to  prevent 
venous  return,  but  not  so  great  as  to  interfere  with  the  ingress  of  arte- 
rial blood.  The  limbs  are  thus  engorged  with  blood  which  cannot  return 
to  the  heart.  Hence  there  is  less  blood-pressure  at  the  point  of  hemor- 
rhage, and  spontaneous  arrest  is  encouraged.  This  device  is  ingenious, 
and  may  perhaps  l)e  serviceable  in  inaccessible  hemorrhage  of  the  trunk 
and  viscera. 

Hemorrhage  renders  patients  thirsty  because  of  the  draining  of  the 
liquids  of  the  body.  Hence  water  and  liquid  foods  are  acceptable  and 
valuable.  Perhaps  water  containing  saline  ingredients  would  be  prefer- 
able to  simple  water.  Tonics,  stimulants,  and  concentrated  diet  should 
1)6  administered  subsequent  to  profuse  hemorrhage,  to  replenish  the  loss 
of  the  vital  fluid. 

Tkaxsfision. — When  death  from  violent  hemorrhage  is  imminent, 
transfusion  of  blood  taken  from  another  person  who  is  vigorous  and 
healthy  is  proper.  Venous  or  arterial  blood  may  be  used,  and  it  may  be 
injected  into  a  vein  or  an  artery.  Venous  blood  is  generally  preferred, 
because  more  readily  obtainable,  and  is  usually  transfused  into  a  vein  of 
the  arm.  If  the  blood  is  transfused  froui  the  donor  to  the  receiver  with- 
out being  subjected  to  manipulation,  the  operation  is  direct  transfusion. 
The  indirect  method  consists  in  drawing  the  blood  into  a  receptacle,  re- 
moving the  fibrine  by  whipping,  and,  after  straining  the  defibrinated 
blood,  injecting  it  by  a  syringe  into  the  circulation  of  the  patient. 

In  performing  the  operation  it  is  important  to  avoid  the  injection  of 
portions  of  clot,  and  to  prevent  the  entrance  of  air  into  the  patient's 
circulation.  The  quantity  of  blood  transfused  should  not  exceed  eight 
or  ten  fluidounces,  and  should  be  injected  very  slowly.  It  is  not  unusual 
for  a  marked  chill  to  follow  the  procedure. 

Direct  transfusion  is  readily  accomplished  by  Aveling's  apparatus. 
This  consists  of  a  rubber  tube,  with  a  bulb  without  valves  in  the  centre, 
and  metallic  caps  with  stopcocks  at  each  end  ;  and  two  canulas  or  metal 
tubes  for  insertion  into  the  veins  of  the  donor  and  recipient.  The  canulas 
can  be  attached  at  will  to  the  caps  of  the  rubber  tubes  by  an  air-tight 
joint.  When  transfusion  is  to  be  done,  the  rubber  tube  and  bulb  are 
filled  with  warm  water  and  the  cocks  turned  to  prevent  its  escape.  The 
largest  vein  at  the  bend  of  the  elbow  of  the  patient  is  then  opened  by  a 
flap  incision  made  with  a  sharp  bistoury,  and  a  canula  filled  with  warm 
water  introduced  into  the  vein  with  the  point  directed  toward  the 
patient's  shoulder.  The  external  opening  of  this  canula  must  be  closed 
by  an  assistant's  finger  to  prevent  escape  of  the  water.  A  similar  vein 
in  the  donor's  arm  is  immediately  opened  and  the  other  canula  inserted 
with  its  point  toward  the  hand.  From  this  a  little  blood  should  be  allowed 
to  flow  to  drive  out  the  air.  The  rubber  tube,  or  syringe,  filled  with 
warm  water  is  now  attached  to  the  two  canulas  and  both  stopcocks  opened. 
The  canulas  must  be  held  in  place  by  assistants  or  by  the  veins  being  tied 
around  them.  The  surgeon  with  a  thumb  and  finger  presses  together  the 
sides  of  the  tube  at  any  point  between  the  bulb  and  the  donor's  arm,  and 
then  compresses  the  bulb.  By  this  manoeuvre  the  warm  water  in  the 
apparatus  ifsij)  is  injected  into  the  patient's  circulation.      The   thumb 


HEMORRHAGE. 


229 


and  finger  are  then  api)lied  to  the  tube  near  the  recipient's  arm,  and  the 
bulb  is  allowed  to  dilate.  Thus  about  two  drachms  of  blood  are  sucked 
out  of  the  donor's  arm,  and  are,  by  a  repetition  of  the  previous  process, 
thrown  quietly  and  slowly  into  the  vein  of  the  patient.  If  the  surgeon 
prefers,  he  can  force  the  water  out  of  the  syringe  and  let  it  and  the  tube 
fill  with  blood  before  connecting  the  apparatus  with  the  patient's  canula. 
Then  no  water  is  transfused,  except  the  very  small  amount  contained  in 
that  canula. 

Fig.  85. 


Aj)paratus  for  direct  transfusion. 


Indirect  transfusion  is  accomplished  by  withdrawing,  as  in  ordinary 
venesection,  about  ten  fluidounces  of  blood  from  the  donor  and  receiving 
it  in  a  small  vessel  surrounded  by  hot  Avater  (110^).  The  blood,  thus 
kept  warm,  is  deprived  of  its  fi brine  by  whipping  with  a  fork  or  bundle 
of  straws.  After  being  filtered  through  a  cloth  or  strainer  the  defibrinated 
blood  is  slowly  injected  by  means  of  an  ordinary  syringe  attached  to  a 
canula,  which  has  previously  been  inserted  into  the  vein  of  the  patient. 
The  syringe  and  canula  must  have  the  air  expelled.  Elaborate  apparatus 
has  been  devised  for  facilitating  these  steps,  but  it  is  not  always  possible 
to  obtain  such  instruments  when  needed,  and  the  simple  means  described 
is  efficient. 

In  both  modes  of  transfusion  it  is  often  preferable  to  isolate  the 
patient's  vein  before  opening  it,  and  to  apply  a  ligature  around  it  and 
the  point  of  the  canula  after  the  latter  is  placed  in  jjosition.  These  pro- 
cedures must  be  carried  ou  under  rigid  asepsis. 

Instead  of  human  blood,  lamb's  blood,  milk,  and  saline  solutions  have 
been  transfused  with  some  apparent  benefit. 

Local  Measures. — In  all  cases  of  bleeding  the  first  step  is  to  clean 
the  wound  and  remove  the  loose  clots.  Afterward  that  means  of  check- 
ing hemorrhage  is  selected  which,  while  securing  immunity  from  recur- 
rence of  bleeding,  best  assists  Nature's  efforts  and  offers  least  obstruction 
to  rapid  healing.  When  operating,  the  surgeon  should  bear  in  mind  that 
many  fluidounces  of  blood  can  be  lost  without  very  serious  injury,  and 
also  that  no  artery  or  vein  can  bleed  if  it  is  compressed  by  the  fingers. 
These  facts  give  assurance  that  there  is  always  time  and  means  to  control 
the  bleeding,  at  least  temjDorarily.     Many  arteries  that  spurt  freely  when 


230  DISEASES    AND    INJURIES    OF    BLOODVESSELS. 

tirst  divided  soou  stop  bleeding.  Venous  hemorrhage  usually  requires  no 
treatment  for  it,  and  unless  from  large  veins,  ceases  spontaneously. 

Elevation  of  the  part  has  a  tendency  to  check  arterial  bleeding,  and 
loosening  of  tight  clothing  or  constricting  surgical  dressings  will  often 
cause  venous  oozing  below  the  constricticm  to  cease.  In  the  first  case  the 
force  of  the  arterial  circulation  is  lessened  ;  in  the  latter  the  impediment 
to  the  upward  flow  of  blood  is  removed  and  the  consequent  distention  of 
the  veins  prevented.  Exposure  of  the  bleeding  surface  to  the  air  or  the 
action  of  cold  water  or  ice  induces  contraction  of  the  vessels  and  diminu- 
tion of  hemorrhage.  Laying  open  a  bleeding  cavity  or  removing  the 
warm,  poultice-like  clots  from  a  wound  has  a  tendency  to  check  loss  of 
blood  from  small  arteries  and  capillaries.  Ice  may  be  thrust  into  bleed- 
ing cavities,  but  its  chilling  and  depressing  influence  must  be  watched. 

Chemical  agents  with  astringent  properties  are  employed  in  surgery  as 
blood-arresters,  under  the  name  of  styptics,  because  of  their  tendency  to 
promote  contraction  of  the  vessels  and  surrounding  tissues,  and  because 
of  their  inducing  rapid  coagulation  of  the  blood.  The  most  common 
styptics  are  subsulphate  of  iron,  perchloride  of  iron,  alum,  the  salts  of 
copper,  zinc  and  silver,  tannic  acid,  gallic  acid,  and  various  combinations 
of  these  with  other  ingredients.  They  are  employed,  either  in  powder  or 
solution,  upon  a  sponge  or  piece  of  cloth,  which  is  applied  to  the  bleeding 
surface.  If  the  hemorrhage  is  from  veins,  capillaries,  or  small  arteries, 
styptics  may  arrest  it,  but  are  needless  because  pressure  by  means  of  com- 
presses or  bandages  is  better. 

If  arteries  of  any  importance  are  the  source  of  bleeding,  styptics  are 
ineflicient  and,  therefore,  worthless.  Hence,  as  they  are  either  needless 
or  ineflicient,  and  are  apt  to  be  means  of  infecting  the  wound  with 
bacteria,  I  regard  styptics  as  useless  agents  for  controlling  such  bleeding 
as  is  met  in  general  surgery. 

They  are  objectionable  because  pi-actitioners  resort  to  them  and  lose 
valuable  time  when  ligation,  torsion,  or  acupressure  is  required.  Many 
of  them,  moreover,  by  irritating  the  surface  and  covering  it  with  pasty 
clots,  or  by  infecting  it  with  pyogenic  or  putrefactive  germs,  prevent  union 
by  first  intention.  Hot  water  of  about  120°  F,,  locally  applied,  causes 
blanching  of  the  surface  and  cessation  of  hemorrhage.  It  has  the  advan- 
tage over  ice  of  not  depressing  the  patient.  All  the  methods  thus  far 
mentioned  are  greatly  inferior  to  pressure  and  to  occlusion  of  each  indi- 
vidual vessel  by  ligation,  torsion,  or  acupressure.  These  merit  careful 
description,  for  they  and  the  actual  cautery  are  the  only  scientific  and 
satisfactory  modes  of  dealing  with  the  hemorrhages  usually  observed  by 
the  surgeon. 

When,  as  in  deep  cavities  without  bony  walls,  it  is  diflicult  or  impossible 
to  use  ligatures  or  pressure,  the  cautery  iron,  heated  only  to  a  black  or 
dull  red  color,  may  be  employed  to  seal  the  vessels  by  converting  the 
tissues  into  a  dry  eschar.  Lidell  advises  in  parenchymatous  hemorrhage 
water  of  not  less  than  16U°  F.  before  resorting  to  cauterization.  The 
water  probably  acts  by  coagulating  the  albumen. 

Pre.-imre  is  well  adapted  for  temporarily  arresting  hemorrhage  until 
ligation,  amputation,  or  other  operative  measures  can  be  performed.  It 
is  also  of  great  value  in  the  permanent  arrest  of  bleeding  in  those  cases 
when  there  is  no  vessel  of  sufficient  importance  to  require  ligation,  torsion, 
or  acupressure.  In  my  opinion,  pressure  and  ligation  are  the  only  hemo- 
static agents  that  the  surgeon  needs.  Applied  to  the  main  artery  in  its 
continuity,  pressure  limits  the  flow  of  blood  to  the  wound  and  thus  checks 


HEMORRHAGE.  281 

bleeding.  This,  which  may  be  called  arresting  hemorrhage  by  indirect 
pressure,  is  generally  accomplished  by  means  of  a  tourniquet,  or  by 
pressure  of  the  fingers.  The  pressure  may  also  be  obtained  by  using  a 
conical  bag  of  shot,  or  a  pyramidal  compress  with  a  coin  at  its  apex,  or  by 
placing  a  roll  of  cloth  in  the  flexure  of  a  joint  and  bandaging  the  joint 
in  a  strongly- flexed  position.  These  methods  are  liable  to  do  harm 
because  they  often  interfere  with  the  return  circulation  in  the  veins  and 
thus  induce  congestion  and  oedema  of  the  structures  between  the  wound 
and  the  point  where  pressure  is  made  upon  the  artery.  They  must  be 
watched.  Direct  pressure  upon  the  bleeding  vessels  in  the  wound  is  far 
better.  An  elastic  bandage  applied  over  a  crushed  and  bleeding  foot  will 
stop  all  hemorrhage,  and  is  far  better  than  a  tourniquet  applied  to  the 
femoral  artery,  because,  when  reaction  occurs  and  amputation  is  advisable, 
all  the  structures  above  the  injury  are  in  good  condition  and  free  from 
cedema. 

A  compress  and  an  ordinary  bandage,  applied  evenly  and  with  mode- 
rate firmness,  will  arrest  hemorrhage  from  capillaries,  veins,  and  the 
smaller  arteries.  A  bleeding  cavity  should  be  plugged  with  aseptic  gauze 
or  compressed  sponge,  which  may,  at  times,  be  held  in  position  with  a 
bandage.  Xo  styptic  is  required,  for  the  pressure  causes  approximation 
of  the  vascular  walls,  which  is  followed  by  internal  coagulation,  fibrinous 
exudation,  and  finally,  by  obliteration  of  the  vessel.  In  wounds  that  are 
expected  to  heal  by  first  intention  the  pressure  is  made  upon  the  integu- 
ment, after  the  parts  have  been  properly  adjusted.  When  healing  by 
granulation  is  evidently  the  only  method  of  repair  possible,  as  is  the  case 
in  wounds  made  in  removing  carious  bone,  the  pi^essure  is  made  upon  the 
open  vessels  by  filling  the  wound  with  gauze,  and  applying  a  retaining 
bandage. 

In  using  pressure  the  surgeon  must  recollect  that  great  force  is  not 
required,  and  that  gangrene  may  result  from  tight  bandaging.  The 
oozing  of  blood-stained  serum  through  the  dressings  must  not  be  mistaken 
for  a  continuance  of  the  hemorrhage.  Enough  gauze  dressing  should  be 
applied  to  prevent  the  possibility  of  this  serum  reaching  the  surface,  and 
becoming  septic  between  the  surgeon's  visits.  A  considerable  degree  of 
pressure  may  be  made  with  impunity  if  there  is  a  voluminous  gauze- 
dressing  over  the  wound,  because  the  elasticity  of  the  dressing  prevents 
the  constriction  from  coming  directly  upon  the  tissues. 

When  bleeding  from  a  wound  is  profuse,  digital  or  instrumental  pres- 
sure should  be  made  upon  the  main  artery,  while  the  surgeon  is  tying  or 
securing  the  vessels  in  the  wound.  The  pressure  can  then  at  intervals 
be  relaxed  momentarily  to  allow  the  bleeding  vessels  to  become  distin- 
guishable. 

The  common  carotid  artery  is  controlled  by  pressure  made  at  the  inner 
border  of  the  sterno-mastoid  muscle,  on  a  level  with  the  cricoid  cartilage, 
and  directly  backward  and  inward  against  the  cervical  vertebrae. 

The  subclavian  artery  is  controlled  by  pressure  made  above  the  clavicle 
at  the  outside  of  the  sterno-mastoid  muscle,  and  directly  downward,  and  a 
little  inward  against  the  first  rib. 

The  axillary  artery  in  controlled  by  pressure  made  along  the  inner  border 
of  the  biceps  muscle  and  directed,  through  the  upper  part  of  the  artery's 
course,  outward  against  the  shaft  of  the  humerus. 

The  femoral  artery  is  controlled  by  pressure  made  below  the  middle  of 
Poupart's  ligament,  and  directed  upward  and  backward  against  the  head 
of  the  femur  and  ramus  of  the  pubic  bone. 


232  DISEASES    AND    IXJUKIES    OF    BLOODVESSELS. 

Occ'LUsrox  15Y  Li<;atiox,  Tohsion,  and  Acupressirk. — AVlien  hem- 
orrhage comes  from  arteries,  whos^e  calibre  e(|uals  or  exceeds  that  of  the 
facial,  or  from  veins  which  are  so  situated  that  pressure  cannot  be  ^vell 
applied,  each  vessel  must  be  separately  treated.  The  methods  em])loyed 
to  bring  the  walls  of  the  artery  or  the  vein  into  apposition,  and  thus  close 
the  lumen,  are  ligation,  torsion,  and  acupressure.  The  best  and  most  fre- 
quently used  is  ligation. 

Ligation  is  simply  tying  a  string  tightly  around  the  vascular  tube,  and 
thus  completely  closing  its  calibre.  Ligatures  are  usually  round  cords  of 
silk  or  catgut ;  though  wire,  tendon,  and  other  materials  are  occasionally 
employed.  Flat  ligatures  are,  as  a  rule,  not  desirable.  Catgut  ligatures 
are  best  prepared  l)y  the  method  described  for  the  pre])aration  of  anti- 
septic sutures  in  the  chapter  on  Essentials  of  Practical  Surgery.  They 
should  be  kept  stored  in  alcohol,  and  soaked  in  a  beta-naphthol  or  subli- 
mate solution  before  being  used.  Silk  ligature  must  be  made  aseptic  by 
boiling,  or  antiseptic  by  soaking  in  an  antiseptic  solution  before  use.  A 
convenient  length  for  a  ligature  is  eight  to  ten  inches,  since  such  a  cord 
can  be  readily  drawn  into  a  firm  knot  by  the  fingers. 

When  an  artery  is  tightly  tied  with  a  ligature  the  external  coat  is  deeply 
grooved  by  the  constricting  cord,  while  the  middle  and  inner  tunics  are, 
on  account  of  their  brittleness,  cleanly  divided.  The  coats  thus  cut  curl 
up  more  or  less  within  the  lumen  of  the  artery,  and  aid  the  coagulation 
and  fibrinous  exudation  which  permanently  seal  the  vessel.  If  the  liga- 
ture is  septic,  or  becomes  so,  the  external  coat  of  the  vessel  gradually 
ulcerates  at  the  constricted  point,  so  that,  in  the  course  of  a  few  days  or 
weeks,  the  noose  of  thread  is  found  lying  loose  in  the  wound.  Sometimes 
a  little  slough  from  the  external  coat  is  found  in  the  noose  when  the  liga- 
ture becomes  detached.  Aseptic  or  antiseptic  catgut  and  similar  absorb- 
able ligatures  become  absorbed  in  a  week  or  two,  and  do  not  cause  ulcer- 
ation of  the  outer  tunic.  Wire  and  silk  ligatures,  if  not  septic,  may 
become  encysted.  Septic  wounds  are  more  liable  to  secondary  hemor- 
rhage than  aseptic  wounds,  because  of  this  possibility  of  ulceration  and 
sloughing  occurring  in  the  vessels. 

Veins  have  such  pliable  coats,  that  none,  as  a  rule,  are  divided  by  the 
ligature,  but  all  are  simply  corrugated  at  the  point  of  constriction. 

AVhen  a  divided  vessel  in  a  wound  is  to  be  ligated  the  surgeon  either 
seizes  the  bleeding  end  with  a  pair  of  catch  forceps  and  draws  it  out  from 

Fig.  S6.  Fig.  87. 


Granny  knot,  which  is  uev  Flat  or  reef  knot.  (J.D.Bryant.) 

surgery.  (J.  D.  Bryant.; 

the  cellular  and  muscular  tissue  in  which  it  is  imbedded,  or  thrusts  a 
sharp  hook,  called  a  tenaculum,  into  the  wall  of  the  vessel,  or  the  tissue 
surrounding  it.    The  ve.ssel  is  then  isolated  from  other  structures,  as  much 


HEMORRHAGE. 


238 


as  possible,  and  the  ligature  tied  beyond  the  forceps  or  tenaculum,  in  a 
reef,  or  flat  knot.  (Figs.  86  and  87.)  Care  should  be  taken  not  to  include 
any  nerve  in  the  ligature.  The  accompanying  veins  and  the  muscular 
tissue  around  an  artery  are  usually  separated  from  it  before  the  ligature 
is  applied  ;  but  in  smaller  arteries  it  does  no  harm  to  include  these  in  the 
knot. 

When  the  knot  is  tightened,  the  forefingers  or  thumb  should  be  placed 
upon  the  string  close  to  the  artery  and  firm,  steady  traction  made.  (Fig. 
88.)  The  amount  of  force  required  to  tie  even  a  large  artery  is  not  very 
great,  and  it  should  be  done  without  jerking. 

Fig.  88. 


Manner  of  tightening  ligatures. 

The  giving  away  of  the  inner  and  middle  coats  is  often  distinctly  felt 
by  the  surgeon.  Ligation,  as  a  rule,  merely  corrugates  the  inner  coats  of 
the  veins.  Catgut  ligatures  should  be  given  an  additional  third  tie,  be- 
cause of  the  liability  of  the  knot  when  made  with  catgut  to  become 
loosened ;  or  they  should  be  tied  in  the  so-called  friction  or  surgical  knot. 
The  ligature  should  have  both  ends  cut  off  about  one-tenth  of  an  inch 
from  the  knot. 

The  method  of  applying  ligatures  to  arteries  in  continuity,  for  the  arrest 
of  hemorrhage  at  a  distant  point  and  for  the  treatment  of  aneurism,  will 
be  described  in  the  section  which  treats  of  the  special  ligations. 

There  are  five  rules  to  guide  the  surgeon  in  the  use  of  ligation  for 
arresting  arterial  hemorrhage : 

I.  In  cases  of  primary  hemorrhage  do  not  ligate  arteries  which  are  not 
actually  bleeding  at  the  time,  but  have  the  patient  carefully 
watched. 

Reasons  for  this  rule  : 

1.  It  is  very  possible  that  bleeding  has  permanently  ceased. 

2.  It  is  difiicult  to  be  sure  from  which  arteries  the  bleeding  came. 

3.  All  manipulations  in  Avounds  are  to  be  avoided  unless  demanded. 
Exceptions  to  this  rule  : 

1.  When  a  large  vessel  is  plainly  seen  pulsating  in  the  wound. 

2.  When  the  occurrence  of  even  slight  secondary  hemorrhage  would 

be  disastrous ;  as  in  a  very  anaemic  patient. 

3.  When,  as  in  transportation,  the  patient  will  necessarily  be  away 

from  surgical  scrutiny. 


23-1  DISEASES    AND    INJURIES    OF    BLOODVESSELS. 

II.  In   cases  of  primari/  and  of  srcDiiddrif  hemorrhage   the    ligature 

shonhl  be  applied  when  practicable   in  the  wound   at  the  point 
where  the  artery  bleeds,  and  not  in  the  continuity  of  the  vessel. 
Reasons  for  this  rule: 

1.  It  is  frequently  impossible  to  know  which  artery  is  injured  until 

the  wound  is  opened. 

2.  Secondary   hemorrhage  may  occur,  even  after  ligation  in   con- 

tinuity from  the  establishment  of  the  collateral  circulation. 
This  secondary  bleeding  may  come  even  from  the  proximal  end 
of  the  cut  vessel,  if  a  branch  of  considerable  size  is  given  oft 
between  the  wound  and  the  point  of  ligation. 

3.  Ligation  in  continuity  makes  a  second  wound,  and  adds  the  pos- 

sible complication  of  this  wound  to  the  patient's  original 
dangers. 

4.  Ligation  in  continuity  remains,  as  a  reverse  step,  still  possible,  if 

ligation  in  the  wound  fails. 
Exceptions  to  this  rule  : 
None. 

III.  If  the  artery  is  completely  severed  both  ends  should  be  tied  ;  if  it 

is  partly  divided  or  punctured,  a  ligature  should  be  applied  to 
the  vessel  on  each  side  of  such  wound. 
Reason  for  this  rule  : 

The  collateral  circulation  will  probably  cause  secondary  hemorrhage 
from  the  distal  portion  of  the  vessel,  unless  double  ligation  be 
adopted. 
Exception  to  this  rule  : 

When  the  distal  end  cannot  be  found,  pressure  must  be  made  in  its 
neighborhood. 

IV.  If  a  large  artery  is  wounded    near  its  origin,  tie  it  below  the 

wound,  and  tie  the  trunk,  from  which  it  arises,  both  above  and 
below  the  point  of  origin  of  the  branch.  If  a  trunk  is  wounded 
near  the  origin  of  a  large  branch,  tie  the  trunk  with  two  liga- 
tures in  the  ordinary  manner,  and  apply  a  third  ligature  to  the 
branch. 
Reasons  for  this  rule  : 

The  force  of  a  large  current  of  blood  near  the  internal  coagulum 
may  lead  to  its  displacement,  and  cause  secondary  hemorrhage 
when  the  silk  suture  causes  ulceration  of  the  external  coat,  or  the 
catgut  or  flat  ligature  is  absorbed. 
Exception  to  this  rule  : 
None. 

V.  When   it  is  impossible  or  impracticable  to  tie  the  vessel  in  the 

wound,  as  in  deep  wounds  of  the  pelvis,  ligation  in  continuity 

may  be  permitted. 
Torsiofi  consists  in  occluding  the  cut  end  of  the  vessel  by  twisting  it 
on  its  long  axis.  This  is  done  by  seizing  the  end  of  the  cut  artery  with  a 
pair  of  catch  forceps,  drawing  it  out  of  the  sheath  and  giving  it  four  or 
five  sharp  rotations.  This  twisting  in  the  case  of  large  arteries,  like  the 
femoral,  should  be  repeated  until  the  sense  of  resistance  has  ceased ;  but 
the  end  should  not  be  twisted  off".  By  this  manoeuvre  the  middle  and 
inner  coats  are  lacerated  and  curl  up  within  the  lumen  of  the  artery, 
while  the  external  tunic  is  twisted  into  a  cord.  This  acts  as  a  temporary 
plug  until  the  internal  coagulum  and  exudation  of  lymph  are  enabled  to 
prevent  hemorrhage  and  permanently  close  the  orifice. 


HEMORRHAGE, 


235 


The  twisted  end  is  sometimes  thrown  off  as  a  small  slough  ;  but  if  kept 
aseptic  it  becomes  blended  with  the  adjacent  structures  and  is  converted 
into  fibrous  tissue.  In  dealing  with  small  arteries  the  ends  may  be 
twisted  entirely  off  with  impunity. 


Fig. 


of  - 
Artery, 


Twisted  end 
qfJj'tery. 


Inverted  aid  of  imier  Coats 

Torsion  of  an  arterv.     TBrtant.) 


Fig.  90. 


Effects  of  torsion  on  arterial  coats. 


Some  operators  perform  limited  torsion  instead  of  the  free  torsion  just 
described.  Limited  torsion  is  performed  by  drawing  the  vessel  out  and 
grasping  it  transversely  a  little  above  the  end  with  a  second  pair  of  for- 
ceps. When  rotation  is  then  made  by  means  of  the  first  forceps  the  effect 
of  the  twisting  cannot  extend  above  the  point  held  by  the  second  pair. 
This  method  is  convenient  when  the  artery  is  loosely  connected  with  sur- 
rounding parts. 

The  ciiief  advantage  claimed  for  torsion  is  that  it  leaves  no  foreign 
material  in  the  wound  as  does  the  ordinary  ligature. 

Aseptic  catgut  or  silk  ligatures  being  either  absorbed  or  encysted  do 
not  act  as  foregin  bodies,  but  allow  the  wound  to  be  at  once  closed.  It 
is,  therefore,  in  this  respect  comparable  to  torsion ;  hence,  as  ligation  is 
much  safer  than  torsion,  I  greatly  prefer  ligation  to  any  form  of  twisting, 
except  for  vessels  of  inconsiderable  size.  When  the  hemostatic  forceps, 
used  to  arrest  hemorrhage  from  cut  vessels  during  the  continuance  of  an 
operation  are  to  be  removed,  a  few  preliminary  twists  given  to  the  vessels 
will  often  avert  the  necessity  of  ligature. 

Acupressure. — Hemorrhage  from  a  divided  vessel  may  be  arrested  by 
introducing  a  long  needle  or  pin  into  the  surrounding  tissues  in  such  a 
manner  as  to  compress  the  artery  or  vein.  This  compression,  called 
acupressure,  may  be  increased  by  adjusting  a  wire  or  thread  around  the 
ends  of  the  pin  as  in  the  harelip  suture,  or  by  twisting  the  tissues  and  the 
artery  during  the  insertion  of  the  pin.  The  pins,  Avhich  must  be  aseptic, 
must  not  be  permitted  to  remain  in  the  tissues  longer,  at  the  furthest,  than 
three  days.  Usually  they  should  be  removed  in  twenty-four  or  forty- 
eight  hours.  The  time  depends  upon  the  size  of  the  artery.  Large  arte- 
ries require  longer  pressure  than  small  ones,  to  insure  against  secondary 
hemorrhage.  Herein  lies  the  chief  objection  to  acupressure.  If  the  pins 
are  removed  too  soon,  secondary  hemorrhage  may  supervene ;  if  they  are 
allowed  to  remain  too  long,  they  may  cause  irritation  or  interfere  with  the 
dressings,  and  there  is  nothing  gained  over  the  use  of  the  ordinary  ligature. 
Acupressure  is  a  valuable  means  of  arresting  bleeding  when  the  surgeon 
has  no  assistants  and  is  in  a  hurry.  It  stops  the  hemorrhage  until  better 
methods  can  be  applied.  It  is  also  useful  as  a  preliminary  to  operations 
■which  must  of  necessity  divide  definite  vessels.  Thus  the  facial  artery  can 
be  compressed  before  cutting  into  the  cheek.     So  also  the  tissues  around 


236  DISEASES    AND    INJURIES    OF    BLOODVESSELS. 

vascular  tumors  can  be  thus  compressed  by  pins  witli  threads  wrapped 
around  the  ends  before  their  excision  is  begun. 

Acupressure  acts  as  a  hemostatic  by  bringing  the  vascular  walls  together 
and  thus  shutting  out  the  blood  current  until  repair  goes  on  by  exudation 
of  lymph  at  the  cut  extremity  of  the  vessel.  An  internal  coagulum  forms 
above  the  point  of  acupressure,  but  does  not  seem  to  play  any  part  in  the 
function  of  the  jiermanent  repair.  Permanent  closure  is  etlected  entirely 
below  the  constriction  caused  by  the  pin  in  the  same  manner  Jis  in  nature's 
method  of  arresting  bleeding  and  repairing  cut  arteries.  If  the  pin 
remains  long  enough  to  destroy  the  structure  of  the  inner  coat,  the  same 
changes  occur  as  after  ligation. 

Acupressure  pins  are  removed  by  seizing  the  head  and  gently  rotating 
and  withdrawing  the  pin  from  the  tissues  while  the  parts  are  supported 
with  the  other  hand  of  the  surgeon. 

Of  the  many  methods  of  obtaining  pressure  upon  an  artery  by  means  of 
a  needle  or  pin  thrust  into  the  tissues  there  are  only  four  that  deserve 
special  attention  and  description  : 

1.  The  point  of  the  pin  is  introduced  through  the  skin  j^erpendicular 
to  the  course  of  the  vessel,  the  free  end  of  the  pin  is  depressed,  the  point 
is  then  carried  across  behind  artery  until  it  emerges  from  the  skin  at  the 

Fk;.  92. 


First  method  of  acupressure.     (Bryast  )  Second  method  of  acupressure.     (Bryant.) 

opposite  side  of  the  vessel.  The  elastic  skin  exerts  sufficient  tension  upon 
the  pin  to  cause  approximation  of  the  arterial  walls.  If  complete  con- 
striction is  not  thus  induced  a  silk  or  catgut  thread  may  be  wrapped 
around  the  exposed  ends  of  the  pin,  as  is  done  in  the  pin  or  harelip 
suture.  This  reinforcement  of  pressure  may  become  especially  necessary 
when  pins  are  introduced  from  raw'  surfaces,  in  which  the  elasticity  of  the 
skin  does  not  exist. 

2.  The  pin  is  thrust  through  a  thick  fold  of  muscular  tissue  at  one  side 
of  the  vessel,  carried  across  the  front  of  the  artery  and  thrust  through  a 
second  thick  fold  of  the  tissue  at  the  other  side.  The  pin  is  thus  pressed 
back  upon  the  artery  by  the  tension  of  the  transfixed  muscular  masses. 
This  method  obliterates  the  calibre  of  the  vessel  best  when  firm  struc- 
tures, such  as  bone,  fascia,  or  skin,  lie  behind  the  ailery  and  furnish 
counterpres'sure. 

I}.  The  pin  is  introduced  parallel  to  the  axis  of  the  artery  through  a 
fold  of  tissue  near  one  side  of  the  vessel ;  the  free  extremity  of  the  pin  is 
rotated  in  the  horizontal  plane  through  one-quarter  of  a  circle,  and  the 
point  is  then  carried  across  the  front  of  the  artery  and  fixed  by  being 
deeply  buried  in  the  soft  structures  on  the  other  side.  The  artery  is  thus 
closed  by  the  twisting  of  its  coats  and  of  the  surrounding  tissues. 

4.  The  pin  is  inserted  at  right  angles  to  the  axis  of  the  artery  through 
a  fold  of  tissue  ;  the  point  is  then  carried  across  the  front  of  the  artery, 
and  the  free  extremity  of  the  pin  rotated  in  the  vertical  plane  through  a 
half  circle  and  the  point  fixed  by  being  deeply  buried  in  the  soft  struc- 


HEMOREHAGE. 


237 


tares  behind  the  vessel.     Occlusion  is  accomplished  somewhat  as  in  the 
jjrevious  method  by  the  twisting  induced  by  the  rotation  of  the  pin. 


Fig.  93. 


Third  method  of  acupressure. 
Fig.  94. 


Fourth  method  of  acupressure. 

Acupressure  is,  in  my  opinion,  far  inferior  to  ligation,  which  method, 
when  aseptic  catgut  or  silk  ligatures  are  employed,  secures  the  greatest 
safety  and  has  no  tendency  to  retard  primary  union. 

When  it  is  difficult  to  apply  ligatures  or  acupressure  in  deep  wounds, 
the  hemostatic  forceps  may  be  used  to  seize  and  close  the  arterial  wound 
and  then  be  allowed  to  remain  so  attached  as  clamps  for  one  or  two  days. 
If  aseptic  they  do  no  harm,  except  to  make  dressing  of  the  wound  a  little 
inconvenient. 

Treatme^tt  of  Secondary  Hemorrhage. — The  prevention  of  sec- 
ondary hemorrhage  is  to  be  secured  by  obtaining  raj)id  union  in  wounds. 
Hence,  absence  of  pus  is  a  primary  factor.  Consequently  antisepsis  and 
provision  for  free  drainage  are  absolutely  demanded. 

When  secondary  bleeding  is  feared  the  patient  should  be  kept  abso- 
lutely quiet,  and  undue  circulatory  activity  controlled  by  aconite,  low 
diet,  laxatives,  and  possibly  venesection.  Morphia  and  ergot  given  in- 
ternally in  full  doses  are  beneficial  from  this  point  of  view.  So  also  is 
partial  compression  of  the  main  arterial  trunk  supplying  the  injured 
region,  and  elevation  of  the  limb  in  which  bleeding  is  feared. 

In  dealing  with  secondary  hemorrhage  the  surgeon  must  not  delay.  In 
primary  hemorrhage  it  is  injudicious  to  take  active  steps  when  bleeding 
has  already  ceased,  unless  the  circumstances  are  exceptional.  The  case  is 
different  in  secondary  bleeding.     The  first  escape  of  blood,  even  in  small 


238  DISEASES    AND    INJURIES    OF    BLOODVESSELS. 

quantity,  calls  for  action,  which  may,  it  is  true,  be  limited  to  elevation  of 
the  part  and  compression  of  the  wound  and  main  artery  l)y  compresses 
and  bandages ;  but  the  second  actual  outbreak  of  homorrhiige  im])era- 
tively  calls  for  prompt  surgical  measures.  If  healing  of  the  wound  is 
still  quite  incomj)]ete  the  sutures  should  be  withdrawn,  the  clots  turned 
out,  and  the  vessel  from  which  bleeding  has  come  securely  ligated.  As 
it  may  be  somewhat  difticult  to  determine  the  exact  source,  every  sus- 
picious point  should  be  ligated.  If  the  softened  or  sloughy  condition  of 
the  wound  surfaces  |)revents  satisfactory  application  of  ligatures,  the 
actual  cautery  may,  ])erhaps,  be  available. 

Opening  the  wound  is  tlie  proper  procedure  even  if  union  is  well  ad- 
vanced, for  the  escaping  bhiod  has  usually  distended  the  wound  cavity 
before  the  existence  of  bleeding  has  been  detected,  and  by  this  action, 
moreover,  the  surgeon  obtains  the  most  accurate  information  possible  of 
the  character  of  the  complication  with  which  he  has  to  deal.  Acupressure 
applied  by  the  first  method  described  on  page  236,  is  often  a  valuable 
means  of  arresting  the  bleeding  either  before  or  after  the  wound  is  re- 
opened. By  thrusting  the  pin  deeply  through  the  tissues  and  reinforcing 
the  pressure  with  a  strong  thread  wraj)ped  around  the  ends,  the  surgeon 
is  enabled  to  compress  parts  in  whicli  one  or  more  bleeding  arteries  are 
situated.  This  manoeuvre  may  be  employed  to  avert  the  necessity  of  lay- 
ing open  the  partially  cicatrized  wound,  or  to  secure  vessels  whose  patulous 
mouths  cannot  be  found  on  the  surface  of  the  wound  because  of  spon- 
taneous cessation  of  ])leeding. 

Instead  of  an  acupressure  pin  a  strong  ligature  may  be  carried  through 
the  tissues  by  means  of  a  long  needle  ;  by  tying  the  ends  of  this  cord 
together  constriction  may  be  effected  that  will  restrain  hemorrhage, 
though  not  sufficiently  great  to  cause  strangulation  and  gangrene. 

The  elastic  bandage  applied  with  only  moderate  firmness  over  the 
wound  at  times  proves  a  valuable  aid  in  resisting  secondary  bleeding. 

When  secondary  hemorrhage  persists  despite  the  direct  treatment  ap- 
plied at  the  seat  of  trouble,  it  is  proper  to  ligate  the  main  artery  in  con- 
tinuity, as  is  done  in  dealing  with  aneurisms.  Such  ligation  should  be 
performed  as  near  the  seat  of  hemorrhage  as  possible  unless  the  anatomical 
relations  of  the  regions  make  it  known  that  the  arterial  anastomosis  will 
soon  establish  such  a  collateral  circulation  that  hemorrhage  will  probal)ly 
recur  in  the  original  locality.  Then  it  becomes  necessary  to  select  a 
higher  point  for  the  deligation.  In  secondary  hemorrhage  of  the  palm, 
for  example,  it  is  usually  better  surgery  to  ligate  the  brachial  artery  than 
to  tie  at  the  wrist  the  radial  or  ulnar  or  both  ;  this  is  a  fact  because  the 
anastomosis  between  the  arteries  of  the  forearm  is  so  free. 

Secondary  hemorrhage  may  supervene  after  an  arterial  trunk  has  been 
tied  in  its  continuity  for  the  cure  of  aneurism  or  the  arrest  of  hemorrhage 
at  a  lower  point.  Here  the  first  step  is  to  apply  pressure  to  the  seat  of 
ligation  by  a  graduating  compress,  or  by  plugging  the  wound.  If  this 
fails  the  wound  must  be  opened  and  a  ligature  applied  at  each  side  of  the 
orifice  in  the  vessel,  which  must  then  be  completely  divided  between  the 
ligatures,  if  the  original  injury  did  not  do  so,  in  oi-der  to  allow  retraction 
and  contraction  of  its  walls.  In  the  event  of  this  being  followed  by  re- 
currence of  hemorrhage,  either  a  second  deligation  in  continuity  at  a 
higher  point,  with  or  without  contemporaneous  ligation  of  one  or  more 
anastomosing  branches,  or  amputation  of  the  limb  must  be  performed. 

Gangrene  is  apt  to  occur  when  a  second  ligation  is  done  in  the  lower 
extremity,  because  the  collateral  circulation  is  rarely  sufficient  to  main- 


WOUNDS    OF    VEINS.  239 

tain  the  vitality  of  the  distant  parts.  Hence,  some  high  authorities  have 
recommended  amputation  rather  than  secoud  ligations  for  persistent  sec- 
ondary hemorrhages  under  such  circumstances. 

When  the  original  source  of  secondary  hemorrhage  is  a  vessel  near  the 
aorta,  pressure  at  the  seat  of  bleeding  is  the  only  resource.  Indeed, 
pressure,  judiciously  applied  by  pads,  plugging,  and  shotbags,  has  at 
times  been  efficacious  when  ligation  above  the  seat  of  hemorrhage  has 
failed.  This  is  due  to  the  circumstance  that  the  escape  of  blood  comes 
very  frequently  from  the  distal  portion  of  the  injured  vessel,  to  which  the 
anastomosing  branches  have  given  an  abundant  blood-current. 


Wounds  of  Veins. 

The  discussion  of  hemorrhage  has  involved  some  consideratitm  of 
wounds  of  veins,  but  a  few  points  remain  that  deserve  more  extended 
attention.  The  dangers  from  wounded  veins  are  hemorrhage,  septicaemia, 
diffiise  phlebitis,  and  entrance  of  air  into  the  heart. 

The  bleeding  from  large  venous  trunks  is  as  fatal  as  arterial  hemor- 
rhage, but  that  from  small  veins  usually  stops  spontaneously  unless  there 
is  some  source  of  constriction  upon  the  cardiac  side  of  the  wound.  Good 
examples  of  this  are  seen  in  the  constricting  bandage  placed  above  the 
elbow  in  cases  of  venesection,  in  order  to  obtain  a  prolonged  and  free 
flow  of  blood  from  the  wounded  vein ;  and  in  protruding  hemorrhoidal 
tumors  pinched  by  the  sphincter  of  the  anus,  which  will  continue  to  bleed 
until  the  anus  is  dilated  by  the  fingers  or  the  tumors  replaced  within  the 
rectum.  Blood  flows  from  wounded  veins  in  a  dark,  rapid  stream  without 
showing  the  pulsatile  action  of  the  heart ;  it  has,  however,  an  increase  in 
its  force  during  each  act  of  expiration,  if  the  seat  of  hemorrhage  is  near 
the  trunk.  Pressure  made  on  the  cardiac  side  of  the  wound  causes  an 
increased  flow  of  blood.  This  may  be  of  diagnostic  value  in  deep  wounds, 
for  blood  from  arteries  may  be  dark  during  anaesthesia,  or  Avhen  the 
bleeding  comes  from  the  distal  end  of  a  divided  artery  in  one  of  the 
extremities. 

Subcutaneous  rupture  of  a  vein  from  violence  may  occur.  The  ex- 
travasation of  blood,  even  if  large,  is  usually  absorbed  in  a  few  days  or 
weeks ;  but  it  may  cause  inflammation  leading  to  abscess,  if  pyogenic 
bacteria  gain  access  to  it,  or  become  encysted  in  a  fluid  state,  giving  rise 
to  the  fluctuating  tumor  called  hematoma.  Contusions  of  veins,  as  of 
arteries,  may  be  unaccompanied  by  symptoms  of  special  import  until 
secondary  hemorrhage  occurs  from  the  ulceration  or  sloughing  of  the 
injured  vessel  wall. 

When  veins  are  completely  divided  slight  contraction  and  retraction  of 
the  coats  occur,  but  not  in  a' sufficient  degree  to  restrain  hemorrhage  from 
the  larger  vessels. 

Incision  and  puncture  of  veins,  when  not  fatal,  usually  heal  rapidly 
and  perfectly  by  first  intention,  leaving  no  scar  and  not  encroaching  on 
the  calibre  of  the  vessel.  Such  is  not  the  case  in  arterial  wounds  which 
are  followed  by  obstruction  of  the  vessel  at  the  seat  of  puncture.  This 
is  well  illustrated  by  the  wound  of  the  median  basilic  vein  made  in  vene- 
section. Small  wounds  of  varicose  veins  or  of  the  larger  trunks  may 
prove  fatal  from  anaemia,  if  the  bleeding  is  not  arrested  by  pressure  or 
ligation.  Injurious  secondary  results  may  follow  when  the  blood  is 
poured  into  the  cavity  of  the  cranium,  thorax,  or  abdomen.     Often  this 


240  DISEASES    AND    INJURIES    OF    BLOODVESSELS. 

is  the  chief  danger.  Wounds,  even  of  the  large  cerebral  sinuses,  are  not 
of  very  grave  prognosis,  if  the  blood  is  given  full  opportunity  to  escape, 
for  moderate  pressure  arrests  the  hemorrhage  in  the-^e  venous  channels  of 
slow  current. 

Wounds  of  small  or  moderate  size  veins  require  little  special  treatment. 
Elevation  of  the  part,  removal  of  all  constriction  of  clothing  on  the 
cardiac  side  of  the  injury,  and  slight  ])ressure  by  a  compre.-^s  and  bandage 
are  sufficient.  In  three  or  four  days  cicatrization  occurs.  Large  veins 
require  ligation.  Styptics  should  never  be  employed.  A  catgut  liga- 
ture should  be  applied  below  and  another  above  the  wound,  if  the  vein 
is  not  completely  divided ;  or  the  wound  may  be  closed  by  fine  catgut 
sutures.  Either  of  these  is  perhaps  a  better  safeguard  against  secondary 
hemorrhage  than  lateral  ligation.  By  lateral  ligation  is  meant  tying  the 
portion  of  the  wall  of  the  vein  immediately  surrounding  the  wound.  This 
is  readily  done  in  large  veins  by  grasping  the  flaccid  coats  of  the  vessel 
with  forceps  and  tenaculum  and  tying  the  ligature  around  the  tissue  so 
seized.  Such  a  ligature  is  possibly  liable  to  slip  oti";  hence  suture  may  in 
some  instances,  at  least,  be  better.  Lateral  ligature  and  suture  do  not 
entirely  destroy  the  continuity  of  the  vessel  as  does  circular  ligation 
above  and  below  the  wound.  Aseptic  ligation  of  veins  is  not  apt  to  pro- 
duce diffuse  phlebitis  and  pyaemia,  a.s  was  formerly  taught.  The  method 
of  repair  after  ligation  of  veins  is  similar  to  that  which  obtains  in  arte- 
rial ligation.  The  ligature  does  not,  however,  cut  the  internal  and 
middle  coats  of  the  vein,  but  merely  corrugates  them ;  or,  at  most, 
divides  only  the  inner  layer  of  the  middle  tunic.  Coagulation  then 
occurs  at  the  distal  side  of  the  ligature,  and  inflararaatory  changes  ensue 
which  permanently  seal  the  vessel.  In  some  cases  the  bleeding  may  be 
satisfactorily  controlled  by  seizing  the  wounded  portion  with  hemostatic 
forceps,  so  placed  as  to  close  the  opening  and  leaving  them  hanging  in 
position  for  twenty-four  or  forty -eight  hours. 

Septicaemia  may  follow  venous  wounds,  if  the  open  vein  or  sinus  is 
surrounded  by  uuhealthy  pus;  hence  absence  of  putrefaction  and  provi- 
sion for  drainage  are  important  features  in  treating  wounds  in  which 
large  veins  are  opened.  Ligation  by  closing  the  open  orifices  tends  to 
prevent  such  septic  infection,  and  is,  therefore,  at  times  advisable  in  major 
operations,  when  sepsis  cannot  be  prevented,  even  when  there  is  no  lia- 
bility to  venous  hemorrhage. 

When  the  large  veins  of  the  extremities,  such  as  the  femoral  or  axillary, 
are  wounded,  ligation  of  the  accompanying  artery  also  may,  according 
to  some  authorities,  be  proper  and  judicious  after  ligation  of  the  vein.  The 
flow  of  blood  to  the  limb  is  thus  diminished  ;  venous  congestion  of  the 
tissues  is  thereby  prevented,  because  the  equilibrium  in  the  capillaries  is 
less  disturbed  ;  and  the  possibility  of  gangrene  is  probably  less.  Further 
evidence  of  the  advisability  of  such  simultaneous  ligation  of  veins  and 
arteries  is  desirable.  I  very  much  doubt  its  propriety  in  the  upper  ex- 
tremity, though  willing  to  admit  its  probable  value  in  wounds  of  the 
femoral  vein. 

Trephining  may  be  required  after  wounds  of  the  sinuses  of  the  dura 
mater  to  allow  the  removal  of  clots  causing  compression  of  the  brain. 
Moderate  pressure  upon  the  injured  venous  channel  with  antiseptic 
cotton  will  control  hemorrhage.  Hemostatic  preparations  of  iron  or 
other  styptics  should  not  be  employed. 

If  from  any  cause  the  wound  in  a  vein  is  kept  widely  open  during 
violent  inspiratory  efforts,  air  may  be  sucked  into  the  venous  circulation 


WOUNDS    OF    VEINS.  241 

and  be  carried  to  the  right  heart.  This  dangerous  accident  is  especially 
liable  to  occur  during  operations  in  the  vicinity  of  the  internal  jugular, 
subclavian,  innominate,  and  axillary  veins  ;  though  it  has  been  stated  that 
it  may  happen  in  veins  of  smaller  calibre  and  in  those  situated  further 
from  the  heart.  The  manner  in  which  wounded  veins  ordinarily  become 
collapsed  during  inspiration  usually  prevents  the  entrance  of  air  ;  hence  it 
is  only  when  some  cause  holds  the  lips  of  the  wound  apart  that  sucking 
air  into  the  veins  is  possible.  This  may  be  due  to  inflammatory  thick- 
euing  of  the  walls  converting  the  vein  into  a  tube,  the  so-called  canaliza- 
tion of  the  veins ;  to  the  vessel  being  imbedded  in  hardened  tissue  or  in 
the  substance  of  tumors,  Avhich  prevents  collapse  ;  or  to  the  eflforts  of  the 
surgeon  who,  in  attempting  to  enucleate  a  tumor  or  foreign  body,  pulls 
the  walls  of  the  vein  apart  at  the  time  of  a  deep  inspiration.  The  acci- 
dent is  less  common  since  the  introduction  of  anaesthesia,  because  there  are 
less  struggling  and  gasping  on  the  part  of  the  patient,  and  more  delibera- 
tion exercised  by  the  surgeon.  It  is  possible,  however,  that  some  of  the 
deaths  attributed  to  anaesthesia  may  be  cases  of  air  in  the  veins. 

The  symptoms  of  entrance  of  air  into  the  veins  are  marked.  During 
the  progress  of  an  operation  a  sudden  sucking  sound  is  heard ;  frothy 
blood  is,  perhaps,  observed  in  the  wound,  the  pulse  fails,  the  heart  beats 
irregularly  and  feebly,  respiration  is  oppressed,  and  syncope  or,  perhaps, 
convulsions  occur.  If  the  amount  of  air  drawn  in  is  small,  recovery 
gradually  takes  place ;  if  the  quantity  is  considerable,  coma  and  death 
supervene.  The  fatal  issue  may  be  immediate,  but  usually  is  postponed 
for  a  period  varying  from  a  few  minutes  to  an  hour.  In  cases  that 
recover  transitory  paresis  has  been  observed.  Secondary  pneumonia  has 
proved  fatal  in  others. 

Occasionally  a  sound  similar  to  that  produced  by  air  entering  the  veins 
occurs  when  the  deep  fascia  of  the  neck  is  incised.  I  was  once  startled 
by  this  phenomenon  when  performing  tracheotomy  for  great  dyspnoea  in 
diphtheria. 

The  pathology  of  the  symptoms  induced  by  air  in  the  veins  is  not 
understood.  It  is  probable  that  the  air,  causing  a  frothy  condition  of  the 
blood  in  the  right  auricle  and  ventricle,  prevents  proper  action  of  the 
valves  and  interferes  with  the  blood  transfer  in  the  pulmonary  circula- 
tion.    Anaemia  of  the  brain  and  other  nerve  centres  is  thus  induced.^ 

This  serious  complication  of  operative  surgery,  which  must  be  quite 
rare,  is  to  be  prevented  by  securing  regular  and  quiet  respiration  during 
anaesthesia,  by  tearing  the  tissues  in  the  vicinity  of  large  veins  apart  with 
fingers  and  dull  instruments,  instead  of  using  the  knife,  and  by  avoiding 
any  posture  of  traction  that  tends  to  keep  venous  Avounds  gaping.  When 
it  becomes  necessary  to  divide  a  large  vein  the  surgeon  should  make  pres- 
sure with  the  fingers  upon  the  vessel  at  the  cardiac  side  of  the  proposed 
wound.  This  should  be  done  also  when  firmly  attached  tumors  are  being 
forcibly  enucleated.  It  has  been  projDosed  to  bandage  the  chest  as  a  pre- 
liminary measure  before  operating  in  the  region  made  dangerous  by  the 
situation  of  the  large  venous  trunks.  Thus  unexpected  deep  inspiration 
is  prevented. 

When  air  has  actually  been  sucked  into  the  veins,  prompt  treatment  is 
demanded.  The  vein  should  immediately  be  compressed  at  the  cardiac 
side  of  the  wound,  and  ligatures  should  then  be  aj^plied  on  both  sides  of 

1  See  N.  Lewis's  paper,  Amer.  Surg.  Assn.,  ISSo. 
16 


242  DISEASES    AND    INJURIES    OF    BLOODVESSELS. 

the  orifice.  The  patient's  head  should  be  h)\vered,  stimulants  should  l)e 
given,  and  artificial  respiration  instituted. 

Galvani.sm  of  the  chest  and  cardiac  region,  transfusion  of  blood  or  of 
warm  water,  tracheotomy,  venesection,  and  pumping  the  air  from  the 
veins  or  even  from  the  heart  by  the  a.spirator,  have  been  ])roposed.  The 
injection  of  warm  water  tlirectly  into  the  heart-cavity  has  been  suggested. 
If  the  symptoms  depend  upon  failure  of  the  valve  action  because  of 
absence  of  fiuid  in  the  heart,  this  may  perhaps  be  a  rational  therapeutic 
measure. 

It  is  probable  that  the  dangers  of  air  in  the  veins  and  heart  have  been 
overestimated. 

DrSEASE-S    OF    THE    VeIXS. 

Inflammation  of  Veins,  or  Phlebitis. 

Varieties. — Inflammation  of  veins  may  be  plastic  or  suppurative. 

Idiopathic  phlebitis  is  rpiite  rare,  but  occasionally  occurs  in  the  course 
of  fevers,  or  as  the  consequence  of  syphilis,  gout,  varicose  veins,  and  pos- 
sibly of  exposure  to  cold.  This  form  of  venous  inflammation  is  more  apt 
to  be  located  in  the  veins  of  the  lower  extremity  than  elsewhere,  and 
does  not  often  assume  the  dangerous  characteristics  that  quite  frequently 
belong  to  traumatic  phlebitis,  l^ecause  traumatic  ])hlebitis  is  often  septic. 
Traumatic  inflammation  follows  contusion,  rupture,  or  incision  of  the 
venous  walls,  and  may  also  be  due  to  violent  muscular  contraction  and 
pressure.  Uterine  ])hlebitis  after  parturition  is  a  phlebitis  possibly  due 
to  the  cause  last  mentioned,  but  probably  a  result  of  microbic  infection. 
Inflammation  of  the  tissues  around  a  vein  may  cause  phlebitis,  which 
should  then  be  considered  a  form  of  traumatic  phlebitis  secondary  to 
peri-phlebitis.  Traumatic  inflammation  of  veins  in  healthy  subjects  is 
usually  a  localized  affection  of  slight  gravity.  If,  however,  septic  changes 
occur  in  the  wound,  especially  it  would  seem  when  the  orifices  of  the 
divided  veins  remain  i)])en,  a  diffuse  or  suppurative  phlebitis,  allied  to 
pvajmia,  and  of  a  most  dangerous  character  may  arise.  Operation  wounds 
of  veins  are  usually  of  slight  gravity,  because  the  consequent  phlebitis  is 
an  uncomplicated  and  localized  adhesive  inflammation. 

Patholouy. — Coagulation  of  blood  in  the  living  veins,  technically 
called  thrombosis,  is  always  an  accompaniment  of  phlebitis.  This  clotting 
may  he  the  cause  of  the  inflammation.  Such  is  the  case  at  times  in  the 
phlebitis  secondary  to  varicose  veins.  Here  the  overstretched  venous 
walls,  with  imperfectly-acting  valves,  allow  retardation  of  blood-current, 
and  the  consequent  thrombosis  sets  up  inflammation  of  the  vascular  tunics. 
On  the  other  hand,  thrombosis  may  be  the  result  of  inflammation,  as  is 
probably  the  case  in  traumatic  phlebitis. 

The  pathological  changes  of  phlebitis  occur  principally  in  the  outer 
and  middle  coats,  which  in  veins,  indeed,  are  scarcely  to  be  considered  as 
two  distinct  tunics.  Hyperyemia  of  these  coats  and  infiltration  of  the 
spaces  between  their  vessels  with  cells  and  serum  are  observed.  These 
changes  necessarilv  induce  swelling,  thickening:  and  loss  of  flexibilitv  of 
the  walls,  which  may  remain  patulous  when  divided.  The  internal  coat 
becomes  cloudy,  fissured  and  shreddy,  and  may  be  separated  from  its 
neighboring  tunic  by  the  disintegrating  influences  of  inflammation.  At 
the  seat  of  inflammation  coagulation  takes  place  within  the  vein  at  an 
early  stage  of  the  phlebitis.     If  the  clot  is  aseptic  and  remains  so,  the 


IXFLAMMATION    OF    VEINS,    OR    PHLEBITIS.  243 

inflammatoiy  process  is  localized.  The  vein  may  then  be  converted  into 
an  impervous  fibrocellular  cord,  as  occurs  after  arterial  ligation.  If  the 
coagulum  adheres  to  only  one  side  of  the  vein,  however,  partial  circula- 
tion may  finally  be  established  through  the  vessel ;  or,  if  complete 
removal  of  the  clot  by  absorption  occurs,  the  calibre  of  the  vein  may  be 
perfectly  restored. 

The  occurrence  of  suppurative  and  gangrenous  inflammation  of  veins 
leads  to  disintegration  or  yellow  softening  of  the  clot,  and  the  dangerous 
septic  elements  are  admitted  into  the  general  circulation. 

As  a  result,  portions  of  the  coagulum  are  worked  loose  and  carried  to 
the  right  heart  and  thence  into  distant  arteries.  Such  plugs  or  emboli 
produce  infarctions  and  abscesses;  and  because  of  an  infective  nature 
lead  to  pysemic  symptoms  and  death.  It  is  for  this  reason  that  phlebitis 
in  broken-down  subjects  or  in  those  suffering  from  infected  wounds,  is 
regarded  as  a  disease  of  grave  prognosis. 

Sytviptoms. — Inflammation  of  a  subcutaneous  vein  gives  rise  in  the 
course  of  the  vessel  to  a  hard  painful  cord,  which  is  accompanied  by 
some  swelling  and  a  distinct  dusky-red  or  copper  color  line  upon  the 
overlying  skin.  The  cord  often  has  a  knotted  appearance  indicating  the 
situation  of  the  valves  of  the  diseased  veiu.  Coagulation  in  the  vessel 
impedes  venous  return  from  the  distal  part  of  the  limb  and  causes  oedema, 
Avhich  may  be  further  increased  by  actual  inflammation  of  the  general 
connective  tissue  of  the  extremity.  In  the  latter  event,  there  is  more  in- 
duration than  in  simple  redema  from  circulatory  obstruction.  Stiffness  of 
the  limb  affected  with  phlebitis  and  pain,  often  of  a  character  resembling 
neuralgia,  are  present.  Phlebitis,  when  not  localized,  usully  extends  in 
the  direction  of  the  heart. 

When  the  deep  veins  only  are  inflamed  the  vessels  are  not  mapped  out 
by  the  subcutaneous  rigid  cords  that  serve  to  distinguish  superficial 
phlebitis,  neither  are  the  copperish  lines  seen ;  but  the  painful  stiffness 
and  oedema  are  perhaps  the  only  indications  of  inflammation.  The 
diagnosis,  consequently,  is  sometimes  difficult. 

The  constitutional  symptoms  are  slight  in  localized  venous  inffamma- 
tion  ;  but  when  the  disease  is  more  extensive,  febrile  movement  is  present. 
In  the  event  of  septic  infection  occurring  in  the  manner  explained  in  the 
paragraph  on  the  Pathology  of  Phlebitis,  chills,  sweats,  high  temperature, 
a  rapid  thready  pulse,  and  delirium  are  to  be  expected.  Under  such 
circumstances  embolic  abscesses  and  death  from  pysemic  svmjDtoms  may 
readily  supervene.  Embolic  abscess  of  the  liver  may  thus  occur  in  portal 
phlebitis.  A  close  connection  exists  between  rapidly-spreading  phlebitis, 
with  its  ulceration  and  gangrene  of  venous  walls,  and  diffuse  cellulitis 
and  erysipelas.  They  all  tend  to  destroy  life  by  the  induction  of  septi- 
caemic  processes ;  and  are  due  to  mycotic  infection.  Non-septic  phlebitis 
is,  even  when  extensive,  of  favorable  prognosis.  Septic  phlebitis  is  a  very 
fatal  disease. 

Phlebitis  is  to  be  distinguished  from  inflammation  of  the  lymphatic 
vessels,  or  angeioleucitis,  by  the  absence  of  glandular  involvement  and 
by  the  darker  red  of  the  cutaneous  line  indicating  the  course  of  the 
affected  vessels.  Neuralgia  and  neuritis  are  unaccompanied  by  the  oedema 
which  almost  invariably  attends  phlebitis. 

Treatment. — Phlebitis  is  to  be  treated  by  absolute  rest  of  the  part 
affected,  and  by  the  avoidance  of  all  causes  that  might  favor  the  separa- 
tion or  disintegration  of  the  intravascular  coagulum.  Pyogenic  and 
putrefactive  infection  must  be  rigidly  averted.     Slight  elevation  of  the 


244  DISEASES    AND    INJURIES    OF    BLOODVESSELS. 

limbs  to  favor  the  return  circulation  is  judicious  and  lessens  pain. 
Leeching,  lead-water  and  laudanum,  mercurial  ointment,  evaporating 
lotions,  fomentations  of  various  kinds,  and  tincture  of  iodine  have  been 
found  useful  as  local  meiisures.  Quinine,  iron,  and  rest  in  bed  are  essen- 
tial in  cases  of  even  moderate  severity.  Cardiac  depressants  are  to  be 
avoided  because  of  the  possibility  that  septicaemia  may  arise  from  unex- 
pected infection. 

When  inflammation  is  spreading  rapidly  up  the  vein,  Mr.  Lee  suggests 
comjM-essing  the  vein  at  two  points — above  the  seat  of  inflammation  by 
acupressure  pins,  and  subcutaneously  dividing  the  vessel  between  them. 

If  suppuration,  great  oedema,  and  diffuse  cellular  inflammation  arise, 
free  incisions,  parallel  to  the  veins,  should  be  made. 

This  procedure  should  be  followed  by  thorough  antiseptic  irrigation  and 
drainage. 

To  remove  the  swelling  and  hasten  the  absorption  of  inflammatory 
deposits,  due  to  phlebitis  of  a  chronic  type,  elevation,  friction,  massage, 
and  pressure  by  the  elastic  bandage  should  be  employed. 

Hypertrophy  and   Varicosity  of  Vein.?. 

Definition. — When  an  abnormal  quantity  of  blood  is  constantly 
carried  by  a  vein,  the  vessel  becomes  enlarged  in  calibre  and  thickened 
in  its  coats.  This  constitutes  hypertrophy  of  veins  ;  and  is  seen,  for  ex- 
ample, when  obstruction  of  a  vena  cava  causes  enlargement  of  the 
external  epigastric  vein  and  the  veins  of  the  anterior  walls  of  the  chest, 
and  in  other  instances  of  unusual  development  of  the  collateral  venous 
circulation.  No  treatment  is  required,  for  the  condition  is  a  corapeusa- 
tory  one.  When  the  amount  of  blood  in  a  vein  is  diminished,  as  happens 
after  amputations,  venous  atrophy  results. 

Varicose  veins  are  veins  which,  on  account  of  disease  of  the  walls,  have 
become  enlarged  and  more  or  less  irregularly  dilated  and  thinned,  and  in 
which  the  blood  current  is  abnormally  retarded.  Varix,  or  varicose  vein, 
is,  therefore  a  condition  that  should  be  distinguished  from  hypertrophy 
of  veins. 

Pathology. — Varicosity  is  most  frequently  met  with  in  the  veins  of 
the  leg,  spermatic  cord  and  rectum  ;  though  the  condition  may  arise  in 
any  location,  even,  it  is  stated,  in  the  veins  of  o.sseous  tissue.  The  long 
saphenous  vein  is  very  frequently  afiected.  The  condition  is  probably 
due  to  a  paresis  of  the  muscular  tissue  of  the  vessel  wall  depending  upon 
degeneration  of  muscular  fibre  or  imperfect  innervation.  Any  impedi- 
ment of  the  blood  current  acts  as  a  predisposing  cause  of  varicose  veins 
by  increasing  the  intravenous  hydrostatic  pressure.  Hence  gravity  has 
long  been  regarded  as  a  prominent  factor  in  the  production  of  varix.  I 
doubt  whether  such  causes  are  capable  of  giving  rise  to  varicosity,  when 
collateral  venous  circulation  is  possible,  unless  at  the  same  time  there  be 
some  degenerative  ])rocess  going  on  in  the  venous  walls.  I  should  as  soon 
expect  to  see  aneurismal  dilatation  of  an  artery  produced  by  simple  inter- 
ference with  the  blood  current  without  previous  disease  of  the  arterial 
tunics.  If  the  flow  of  blood  is  arrested  in  an  artery  the  anastomosing 
arteries  become  hypertrophied  ;  so  is  it  in  the  case  of  veins.  If  the  blood 
current  is  impeded  in  one  vein,  the  collateral  circulation  is  established 
and  the  adjacent  veins  become  hypertrophic. 

Heredity,  debility,  continued  standing,  the  wearing  of  tight  garters,  and 


HYPERTROPHr    AND    VARICOSITT    OF    VEINS.  245 

many  other  factors  have  been  accused  as  causes  of  varicose  veins ;  but 
there  must  be  some  as  yet  unknown  influence  that  determines  the  occur- 
rence of  this  pathological  venous  lesion. 

The  pathological  changes  found  in  varix  are  dilatation,  increased  length 
and  tortuosity,  hyperplasia  of  connective  and  other  tissues,  causing  irregu- 
lar thickening  of  the  venous  walls,  incompetent  valves  due  to  partial 
destruction  of  the  leaflets,  or  to  the  impossibility  of  contact  resulting  from 
the  increased  calibre  of  the  vessel,  and  sacculation  similar  in  appearance 
to  the  pouched  condition  of  the  colon.  The  irregular  dilatations,  causing 
sacculation,  are  especially  prominent  at  points  where  two  veins  unite. 

The  wall  in  such  pouches  is  exceedingly  attenuated.  Chronic  inflam- 
matory changes  are  apt  to  arise  in  the  tissues  surrounding  vai'icose  veins, 
causing  oedema,  obstinate  ulcers  and  even  a  condition  resembling  Arabian 
elephantiasis. 

Coagulation  may  occur  within  varicose  veins,  and  thus  induce  inflam- 
mation or  occlusion  and  partial  cure.  Suppuration  may  occur  from 
infection  with  pus  germs.     Calcareous 

degeneration    of    the   clot   sometimes  Fig.  95. 

takes  place,  and  concretions,  called 
vein-stones,  or  phleboliths,  remain. 
These  may  be  either  free  or  adherent 
to  the  wall  of  the  vein.  They  are 
also,  however,  found  in  veins  not  vari- 
cose, and  are  especially  liable  to  occur 

in    the  veins   of  the   pelvis.      It   is  be-  Varicose  vein.     (Bryant.) 

lieved   that   these   pelvic   phleboliths 

may  also  be  formed  outside  of  the  vessel  and  subsequently  penetrate  the 

venous  walls. 

Symptoms. — The  symptoms  of  varix  are,  dull  pain,  a  sensation  of 
weight  or  fulness,  numbness,  and  perhaps  some  impairment  of  power. 
Inspection  shows  a  characteristic,  bluish,  knotted,  soft  tumor,  in  w-hich  the 
dilated  and  tortuous  veins  can  readily  be  recognized.  QEdema,  indura- 
tion, eczema,  and  chronic  ulceration  of  the  skin  are  frequently  present  in 
varix  of  the  leg  of  long  standing.  It  is  probable  that  the  deep  veins  are 
affected  about  as  frequently  as  the  subcutaneous,  but  when  the  affection 
pertains  only  to  the  former  the  diagnosis  is  difficult.  Gay  thinks  muscu- 
lar cramps  indicative  of  deep  varix.  Slight  local  varicosities  of  the 
cutaneous  capillary  veins  are  quite  common  in  women,  giving  rise  to  an 
arborescent  appearance  of  the  skin  without  swelling  or  other  symptom. 

Profuse  bleeding  may  supervene  from  perforation  of  a  varix  by  ulcera- 
tion. It  is  improper  to  say  that  the  varicose  vein  bursts,  since  the  ulcera- 
tive process  begins  externally.  The  copious  hemorrhage  probably  comes 
from  the  cardiac  portion  of  the  vein,  which  is  distended  with  blood  and 
furnished  with  diseased  valves  incompetent  to  resist  the  backward  cur- 
rent. Moderate  pressure  with  a  finger  or  compress  will  control  the  bleed- 
ing, which,  if  not  arrested,  may  prove  fatal. 

Phlebitis,  with  its  characteristic  thrombosis,  may  be  developed  in  vari- 
cose veins  without  any  specially  assignable  cause. 

Treatment. — The  distress  produced  by  the  existence  of  varicose  veins 
can  be  greatly  palliated  by  such  artificial  support  as  is  obtained  by  cover- 
ing the  limb  with  elastic  webbing,  or  a  rubber  bandage,  applied  smoothly 
and  with  very  moderate  pressure.  To  prevent  cutaneous  irritation  from 
retention  of  secretion  it  may  be  necessary  to  cover  the  skin  with  a  soft 
piece  of  cotton  or  linen  cloth,  before  apjDlying  the  rubber  bandage.     If 


246 


DISEASES    AND    INJURIES    OF    BLOODVESSELS. 


ulceration  exists,  ointments  or  solutious  can  be  thus  applied  before  the 
bandage  is  adjusted.  A  silicate  of  sodium  case,  such  as  is  used  in  treat- 
ing partially  united  fractures,  makes  a  convenient  support  for  varicose 
veins  of  the  leg.  These  appliances  for  j)ressure  should  be  removed  at 
night  only  after  the  patient  lias  a-ssumed  the  recumbent  posture. 

Elevation  of  the  leg  while  keeping  the  patient  in  bed  and  pressure  of 
this  sort  will  greatly  hasten  the  cure  of  eczema  and  ulcers  complicating 
varicose  veins  of  the  lower  limbs. 

The  radical  treatment  of  varicose  veins  depends  upon  occlusion  of  the 
calibre  of  the  vessel ;  or,  in  other  words,  upon  obliterating  the  vein  at  the 
point  operated  upcm,  and  thus  compelling  anastomosing  veins  to  carry  on 
the  circulation.  The  symptoms  of  varix  are  removed  at  the  points  of 
operation,  and  much  relief  may  thus  be  afforded  the  patient;  but  the 
condition  persists,  or  is  soon  developed  in  the  adjacent  veins,  either  super- 
ficial or  deep.  There  is  a  risk,  though  an  exceedingly  slight  one,  of 
inducing  dangerous  phlebitis  by  these  operations,  for  the  so-called  radical 
treatment  of  varix.  Such  measures  are  to  be  recommended  when  incon- 
venience, pain,  intractable  ulceration,  or  the  danger  of  hemorrhage  from 
perforation  renders  the  patient  uncomfortable.  Antiseptic  surgery  renders 
these  operations  trivial. 

The  most  approved  methods  are  the  subcutaneous  ligature  and  acu- 
pressure. Subcutaneous  ligation  is  effected  by  carrying  a  catgut  ligature 
beneath  the  dilated  vein  by  means  of  a  straight  needle,  which  is  then 
reentered  at  the  point  of  exit  and  thrust  in  front  of  the  vein  until  it 
emerges  at  the  first  puncture.  Withdrawal  of  the  needle  through  this 
original  opening  causes  the  vein  to  be  subcutaneously  encircled  by  a  loop 
of  catgut. 

Fig.  96. 


SKIN  <y^ 

Diagram  of  subcutaneous  ligation  of  varicose  veins. 


The  ligature  is  then  drawn  tightly  around  the  vein  and  the  ends  tied. 
The  coats  of  the  vein  are  thus  brought  into  apj)osition  and  internal  coagu- 
lation, with  consequent  local  plastic  inflammation  and  occlusion,  results  at 
as  many  points  as  the  surgeon  has  ligated.  The  catgut  ligatures  become 
absorbed  and  need  no  attention.  The  veins  should  be  ligated  at  numer- 
ous points,  and  care  must  be  taken  to  avoid  transfixing  the  vessel  with 
the  needle.  It  is  well  to  insert  the  ligatui'e  nearest  the  heart  first  and  to 
have  the  limb  dependent,  so  that  the  vein  may  be  distended  to  its  fullest 
capacity. 

Acupressure  acts  in  a  similar  manner.     Harelip  pins  are  thrust  behind 


WOUNDS    OF    LYMPHATICS. 


247 


the  varicose  veins  at  various  points  about  one  inch  apart,  and  the  com- 
pression obtained  by  a  figure-of-eight  or  elliptical  ligature  applied  as  in 
making  the  twisted  suture.     The  uppermost  pins  should  be  inserted  first. 
The  pressure  may  be  increased  by  laying  small  pieces  of  rubber  upon 
the  skin  at  right  angles  to  the  pins  and  tying  the  ligatures  over  these. 


Fig.  97. 


Varicose  veins  treated  by  acupressure.     (Erichsen.) 

The  pins  should  be  withdrawn  after  the  lapse  of  eight  or  ten  days.  A 
modification  of  this  method  is  to  compress  the  vein  with  pins  and  then 
subcutaneously  divide  the  vessel  by  means  of  a  tenotome.  The  pins  are 
removed  in  about  four  days.  Obliteration  of  the  vein  is  thus  insured,  and 
there  is  little  danger  of  septic  phlebitis.  It  is  a  good  method.  Excision 
of  about  two  inches  of  the  vein  through  an  ordinary  cutaneous  incision  is 
a  successful  method.  It  must  be  done  aseptically.  After  any  of  these 
methods  of  operating  a  bandage  should  be  applied  to  the  limb  and  the 
patient  kept  in  bed.  Elastic  stockings  or  rubber  bandages  should  be 
Avorn  after  the  patient  assumes  the  erect  posture. 

Intravenous  injection  of  coagulating  fluids,  such  as  the  iron  salts,  tan- 
nin and  chloral,  peri- vascular  injections  of  ergotine,  the  application  of 
caustic  issues  over  the  varix,  and  excision  of  portions  of  the  dilated  vein 
have  been  advocated.  I  reject  them  as  probably  more  dangerous  than 
subcutaneous  ligation  or  acupressure. 

Patients  with  varicose  veins,  if  debilitated,  should  be  treated  with 
tonics  and  made  to  refrain  from  occupations  that  require  standing  or 
other  positions  favoring  venous  stasis. 

Fluid  extract  of  hamamelis  has  recently  been  recommended  as  an  inter- 
nal remedy  to  be  administered  in  fluidrachm  doses  several  times  daily. 
Its  value,  if  it  has  any,  is  due  to  its  astringent  action.  If  hemorrhage 
occurs  from  varix,  elevation  and  a  moderate  compress  will  stop  it. 

Varicocele  and  internal  hemorrhoids  are  instances  of  varix  in  special 
localities,  which  will  be  discussed  in  subsequent  chapters. 


Diseases  of  Lymphatics. 

Wounds  of  Lymphatics. 

The  lymphatic  vessels  of  the  body,  which  in  their  universal  distribution 
exceed  in  number  the  bloodvessels,  are  injured  in  all  wounds.     Lymph 


248  DISEASES    OF    LYMPHATICS. 

escapes  from  the  several  vessels,  but  is  mixed  with  blood,  and  demands 
no  especial  notice.  It  is  only  when  the  thoracic  duct,  a  large  lyniphatic 
trunk,  or  a  varicose  lymphatic  vessel  is  wounded  that  the  escape  of  lymph 
is  dignified  by  the  name  lymphorrhagia.  The  Huid  thus  discharged  is  at 
times  transparent,  at  others  milky  in  appearance,  and  may  continue 
indefinitely  if  a  fistula  becomes  established  at  the  seat  of  injury.  When 
a  lymphatic  vessel  becomes  occluded  from  pressure  of  a  tumor  or  from 
disease,  collateral  lymphatic  circulation  is  established,  just  as  happens  in 
veins.  The  lymphatic  vessels  and  their  valves  much  resemble  veins  as 
well  in  function  as  in  histology.  Lymphorrhagia  is  to  be  treated  by  pres- 
sure applied  to  the  distal  portion  of  the  vessel,  and  lymphatic  fistulas  by 
compression  and  cauterization.  Incision  of  lymphatic  glands  is  said  to 
have  been  followed  by  lymphatic  fistulas. 


Inflammation  of  Lymphatic  Vessels  or  Lymphangitis. 

Pathology. — Lymi)]iangitis,  or  angeioleucitis,  may  be  idiopathic,  but 
generally  it  is  traumatic.  It  should  be  remembered  that  though  trau- 
matic in  origin,  it  may  first  appear  at  a  distance  from  the  wound.  It  is 
especially  liable  to  follow  injuries  inoculated  with  septic  or  other  micro 
organisms.  Simple  lymphangitis  is  much  less  dangerous  than  the  septic 
form,  which  frequently  has  a  fatal  issue. 

The  pathological  changes  ai'e  similar  to  those  found  in  phlebitis.  The 
lymph  loses  its  transparency,  becomes  opaque,  and  forms  thrombi  or  clots 
of  a  pinkish  color  in  the  vicinity  of  the  valves.  These  clots,  by  adhering 
to  the  vessel  wall  may  cause  occlusion,  or  they  may  break  down  into  pus. 
Thickening,  opacity,  and  dilatation  of  the  walls  of  the  lymphatic  vessels 
occur  and  the  internal  tunic  becomes  uneven.  If  occlusion  is  produced 
the  ducts  anastomosing  with  the  obliterated  vessel  soon  become  distended 
and  carry  on  the  circulation  of  lymph.  The  connective  tissue  about  the 
inflamed  absorbents  becomes  infiltrated  with  lymph  cells  escaping  from 
the  vessels  and  peripheral  a^dema  is  induced  by  obstruction  of  the  lymph 
current  due  to  the  internal  thrombosis. 

The  infiltrated  structures  may  be  relieved  of  this  inundation  by  absorp- 
tive processes,  may  suppurate,  or  may  become  indurated  and  hypertro- 
phied.  It  is  probable  that  occlusion  of  lymphatic  vessels  from  repeated 
lymphangitis  occurring  in  connection  with  cutaneous  changes,  is  a  factor 
in  the  causation  of  certain  cases  of  Arabian  elephantiasis.  Cellulitis  and 
arthritis  may  be  secondary  to  lymphangitis,  and  even  go  on  to  suppura- 
tion. 

Symptoms. — Inflammation  of  the  fine  capillary  absorbent  vessels,  which 
form  an  anastomosing  network,  is  called  reticular  lymphangitis,  while 
inflammation  of  the  larger  ducts  is  termed  tubular  lymphangitis.  Reticu- 
lar lymphangitis  occurs  in  patches,  and  may  or  may  not  be  associated 
with  inflammation  of  neighboring  ducts  of  larger  calibre.  The  adjacent 
glands,  however,  are  nearly  always  involved.  The  patches  are  hot,  red, 
painful,  and  surrounded  by  slight  oedema,  and  may  go  on  to  suppuration. 
Slight  wounds,  such  as  needle  pricks,  at  the  end  of  the  finger,  especially 
when  infected  with  pathogenic  bacteria  and  when  in  debilitated  subjects; 
and  frequent  contact  with  septic  tissues,  even  without  breach  of  surface, 
may  give  rise  to  reticular  absorbent  inflammation,  which  may  be  mani- 
fested by  multiple  spots  of  inflammation  successively  extending  up  the 
limb.     Certain  forms  of  felon  are  instances  of  lymphangitis,  and  the  skin 


INFLAMMATION    OF    LYMPHATIC    VESSELS.  249 

disease  called  erythema  nodosum  is  believed  by  some  authorities  to  be  a 
reticular  lymphangitis,  with  lymphatic  oedema. 

Tubular  lymphangitis,  when  affecting  the  superficial  vessels,  is  mani- 
fested by  the  appearance  of  vivid  red  cutaneous  lines  running  from  the 
primary  lesion  toward  the  heart.  These  lines  mark  the  centre  of  the 
inflamed  ducts  which,  by  palpation,  can  be  felt  as  hard  threads.  There 
may  be  only  slight  tenderness  along  these  red  streaks,  which  by  coales- 
cing make  bands  nearly  an  inch  wide,  but  usually  pain  is  marked  and 
swelling  of  the  limb  observable.  The  nearest  lymphatic  glands  soon 
become  swollen  and  painful.  Subsequently  a  second  group  of  more  dis- 
tant glands  may  be  similarly  involved,  though  there  need  not  be  any 
marked  evidence  of  inflammation  of  the  lymphatic  vessels  connecting  the 
two  glandular  swellings.  Resolution  may  occur  in  a  week  or  ten  days, 
though  suppurative  inflammation  of  the  glands  or  of  the  vessels  is  not 
unusual.  Glandular  implication  is  almost  never  absent  in  lymphan- 
gitis. It  is  stated,  however,  that  in  septic  inflammation  of  the  lym- 
phatics such  involvement  may  at  times  be  wanting  even  when  the  syno- 
vial lymphatic  structures  sho\y  suppurative  processes  of  great  severity. 
The  glandular  inflammation  or  lymphadenitis  results  from  the  arrest  of 
the  causative  bacteria  in  the  sieve-like  sti'ucture  of  the  glands. 

When  the  deep  lymphatics  alone  are  inflamed  the  cutaneous  redness  is 
absent  and  the  symptoms  are  obscure.  Glandular  implication  is  the  only 
symptom  which  enables  a  diagnosis  from  cellulitis  to  be  made. 

In  lymphangitis  the  constitutional  symptoms  are  rigors,  high  tempera- 
ture and  other  febrile  manifestations,  which  in  septic  cases  especially  are 
accompanied  by  great  prostration,  delirium,  and  typical  asthenic  symptoms. 

Violent  lymphangitis  is  often,  probably  always,  due  to  the  introduc- 
tion of  putrefactive  or  other  pathogenic  bacteria  into  the  lymph  current, 
and  is  most  liable  to  occur  when  open  lymphatic  capillaries  are  bathed  in 
or  subjected  to  the  influence  of  septic  fluids.  It  is  developed  not  infre- 
quently in  connection  with  dissection  wounds,  snake-bites,  erysipelas, 
diphtheria,  typhus  and  typhoid  fevers,  and  the  puerperal  condition. 
Uterine  lymphangitis  of  a  septic  character,  which  may  follow  labor  even 
when  no  injury  to  mucous  membrane  has  been  inflicted,  is  very  prone  to 
cause  difflise  peritonitis,  and  is  usually  fatal.  Septic  lymphangitis  may 
arise,  it  would  appear,  without  traumatism  by  an  endosmosis  of  the  poison 
through  the  skin. 

Patients  in  enfeebled  health  are  more  prone  to  septic  lymphatic  inflam- 
mation than  those  of  greater  resistive  power.  This  form  of  lymphangitis 
may  run  an  acute  or  a  chronic  course,  and  is  the  forerunner  of  general 
septicsemic  symptoms. 

Lymphangitis  is  to  be  diagnosticated  from  phlebitis  by  the  higher  febrile 
temperature  of  the  former,  the  more  vivid  red  of  the  cutaneous  lines,  and 
the  associated  glandular  inflammation.  In  erysipelas  the  discoloration  of 
skin  is  more  diflfused  than  in  inflammation  of  the  absorbent  vessels. 

Treatment. — The  treatment  of  lymphangitis  is  very  similar  to  that 
adapted  to  phlebitis.  Septic  infection  is  to  be  prevented  by  cleaning  and 
thoroughly  disinfecting  wounds  at  the  time  of  their  reception.  If  the 
existence  of  poisonous  inoculation  is  suspected  at  the  time,  as  is  the  case 
in  dissection  wounds,  suction  and  cauterization  should  be  employed. 
Absolute  cleanliness  and  antiseptics  should  be  enforced  on  the  part  of 
those  examining  and  attending  puerperal  cases,  since  septic  uterine  lymph- 
angitis is  almost  uniformly  fatal.  Local  applications  may  be  made 
along  the  course  of  the  inflamed  absorbent  vessels  when  superficial.  Moist 


250  DISEASES    OF    LYMPHATICS. 

antiseptic  dressings,  equal  parts  of  extract  of  belladonna  and  glycerin, 
fomentations  containing  morphia  or  other  narcotics,  and  mercurial  oint- 
ment have  been  recommended  as  topical  measures.  Pencilling  with  nitrate 
of  silver  and  wrapping  in  dry  cottim  have  advocates.  The  limb  should 
be  kept  elevated  and  at  rest.  Free  incisions  to  evacuate  pus  must  be 
promptly  made.  Constitutional  remedies  of  a  supportive  kind  are  always 
judicious.  (Quinine,  iron  and  morphia,  and  often  alcohol,  are  the  drugs 
to  be  used.  QEdema  remaining  after  subsidence  of  the  acute  symptoms 
is  to  be  treated  by  pressure  with  the  elastic  bandage,  massage  and  passive 
motion  of  the  joints. 

Ly}nphadenitis. 

PatholO(4Y. — Inflammation  of  a  lymphatic  gland,  called  lymphade- 
nitis or  simply  adenitis,  may  occur  without  the  existence  of  lymphangitis  ; 
but  lymphangitis,  as  previously  stated,  rarely  occurs  without  an  accom- 
j)anying  lymphadenitis.  The  retentive  or  sieve-like  function  of  the  lymph- 
atic glands  is  the  cause  of  their  frequent  implication  secondary  to 
inflammation  of  the  lymph  vessels.  All  material  conveyed  along  any  of 
these  ducts  is  compelled  to  pass  through  the  reticular  or  net-like  structure 
of  the  corresponding  glands.  Here  pigments  from  tattooing,  septic  par- 
ticles, whether  bacteria  or  emboli,  poison  from  syphilitic  or  other  inocu- 
lated wounds,  cells  from  malignant  growths,  pus  and  abnormal  lymph 
cells  are  filtered  out  of  the  retarded  lymph  current  and  remain  to  choke 
up  the  network  of  small  spaces  and  channels  of  which  the  glands  are  in 
large  part  formed.  When  these  filtered-out  particles  cause  stasis  of  the 
current,  coagulation  of  lymph  and  inflammation  of  the  gland  structure, 
then  lymphadenitis,  with  its  characteristic  swelling,  hardness,  and  tender- 
ness, exists. 

Causes. — Lymphadenitis  then  may  be  caused  by  direct  irritation  or 
injury  to  the  gland  or  by  any  peripheral  lesion  or  absorption  that  sends 
irritating  substances  to  the  gland.  The  lymph  vessels  between  the 
periphery  and  the  gland  may  be  free  from  involvement,  even  though  they 
have  carried  the  irritative  cause  in  the  lymph  current  flowing  through 
them.  Lymphadenitis  may  be  acute  or  chronic,  and  is  due  to  infection 
by  the  tubercle  bacillus,  pyogenic  organisms,  and  other  bacteria,  as  well 
as  to  direct  injury.  The  character  of  the  inflammation  depends  on  the 
cause  and  the  constitution  of  the  patient. 

Symptoms. — The  symptoms  of  acute  suppurative  lymphadenitis  are 
swelling  and  tenderness  of  the  gland,  lancinating  pain  increased  by 
motion,  and  fever.  The  connective  tissue  around  the  gland  becomes 
implicated  in  the  inflammatory  process,  the  overlying  skin  assumes  a  red 
and  glazed  appearance,  and  suppuratiou  begins  in  the  centre  of  the  gland 
or  in  the  surrounding  cellular  tissue.  Spontaneous  evacuation  of  pus 
finally  occurs  through  an  irregular  orifice  surrounded  by  thin  purplish 
skin,  which  after  a  prolonged  period  of  cicatrization  heals,  leaving  an 
ugly,  puckered  cicatrix  adherent  to  the  deep  tissues.  Cure  by  resolution 
without  suppuration  takes  place  in  some  instances  of  acute  lymphadenitis, 
but  it  is  so  usually  due  to  pus  infection  that  the  formation  of  pus  is  very 
common.  Sometimes  the  tissues  around  the  gland  suppurate  and  on 
evacuation  leave  the  inflamed  gland  exposed  in  the  wound  as  a  reddish- 
gray  mass.  Tubercular  lymphadenitis,  with  burrowing  of  puriform  fluid 
and  the  formation  of  sinuses,  is  not  very  infrequent.  In  some  cases 
tubercular  adenitis  assumes  a  very  chronic  course,  being  accompanied  by 


VAEICOSE    LYMPHATIC    VESSELS.  251 

glandular  swelling,  induration,  and  hypertrophy  without  pain  or  fever  or 
tendency  to  degenerative  softening.  In  some  regions  of  the  body  the 
lymphatic  glands  are  scarcely  perceptible  by  palpation  through  the 
skin  until  they  become  enlarged  by  inflammation,  when  the  nodulation 
produced  by  them  is  sufficient  evidence  of  adenitis.  The  inguinal  bubo 
occurring  after  syphilitic  inoculation  affords  a  good  example  of  the  behavior 
of  adenitis.  If  a  whole  group  of  glands  is  inflamed,  the  obstruction  to 
lymphatic  circulation  causes  oedema  of  the  peripheral  regions.  This  may 
become  established  if  the  adenitis  is  chronic. 

Septic  lymphadenitis  differs  from  simple  acute  lymphadenitis  in  its 
higher  febrile  movement  and  much  greater  danger  to  life. 

Treatment. — Acute  lymphadenitis  requires  absolute  rest  of  the  part 
and  antiseptic  fomentations  ;  blisters,  or  tincture  of  iodine  painted  around 
the  inflamed  gland  may  be  serviceable.  Pus  should  be  evacuated  by  free 
incision,  and  the  diseased  gland  and  tissues  removed  by  curetting.  Car- 
bolized  oxide  of  zinc  ointment,  iodoform,  and  similar  applications  will 
facilitate  cicatrization  of  the  resulting  ulcer,  which  may  become  chronic 
and  intractable.  All  sinuses  should  be  laid  open  and  scraped.  Chronic 
adenitis  with  its  characteristic  hypertro23hy  is  best  treated  by  blisters, 
tincture  of  iodine,  and  firm  pressure ;  the  last  agent  may  be  applied  by 
means  of  a  specially  adapted  truss.  Interstitial  injections  of  alcohol  by 
means  of  a  hypodermic  syringe  will  often  cause  absorption  and  diminution 
of  large  glandular  masses.  Caseous  tubercular  lymphatic  glands  should 
be  enucleated,  to  prevent  general  infection  of  the  patient ;  as  should 
single  groups  of  indurated  glands  producing  ieformity,  such  as  occurs  so 
frequently  in  the  neck,  if  internal  and  local  treatment  does  not  dissipate 
the  swelling. 

Chronic  adenitis  demands  internal  remedies,  such  as  cod-liver  oil  and 
iodine.  Syrup  of  the  iodide  of  iron  in  full  doses  (n\^xxx-xl),  quinine, 
iron,  nutritious  diet,  and  sea  air  are  very  beneficial,  particularly  in 
strumous  cases. 

Syphilis  and  malignant  and  other  tumors  may  affect  the  lymphatic 
glands,  but  these  topics  demand  no  special  consideration  here.  The  pecu- 
liar disease  variously  called  lymphadenoma,  Hodgkin's  disease,  adeno- 
lympho-sarcoma,  and  malignant  lymphoma,  which  is  attended  by  enlarge- 
ment of  many  groups  of  glands  and  profound  anaemia,  is  a  medical  rather 
than  a  sui'gical  affection. 

Varicose  Lymphatic  Vessels. 

Varicosity,  or  dilatation  of  the  lymphatic  networks  gives  rise  to  small 
transparent  vesicles,  like  boiled  sago  grains,  which  are  more  frequently 
seen  upon  the  inside  of  the  thigh,  and  upon  the  genitals  and  the  abdomen 
than  elsewhere.  When  the  superficial  lymphatic  trunks  are  the  subject 
of  this  infrequent  condition,  the  dilated  portions  give  rise  to  larger  and 
more  elongated  swellings. 

There  is  usually  oedema  of  the  peripheral  parts.  Lymphatic  varicosi- 
ties can  readily  be  emptied  of  their  fluid  contents  by  pressure. 

Arabian  elephantiasis  is  at  times  complicated  with  lymphatic  varicosity. 
Cystic  dilatation  of  the  lymphatic  ducts  occurs  at  times  in  the  tongue, 
lips,  and  neck. 

A  tumor  formed  of  a  congeries  of  dilated  lymphatic  vessels  and  similar 
in  structure  to  the  arterial  and  venous  vascular  tumor,  or  angioma,  is 
occasionally   developed.     It   is   appropriately   called   a   lymphangioma. 


252  INJURIES    AND    DISEASES    OF    ARTERIES. 

Rupture  or  wound  of  a  dilated  lymphatic  ves.sel  is  liable  to  be  followed 
by  lyinphorrhaijia,  or  a  prolonged  discharge  of  lymph.  If  a  fistula  result, 
cauterization  and  pressure  are  proper. 

Lymphatic  dilatation  usually  needs  no  treatment.     The  methods  adopted 
in  corresponding  venous  changes  would  be  applicable. 


Injuries  and  Diseases  of  vVrteries. 
Wounds  of  Arteries. 

Pathology. — After  contusion  of  arterial  coats  there  is  a  liability  to 
ulceration  and  secondary  hemorrhage,  which  occurrence  will,  in  open 
wounds,  demand  prompt  ligation  at  both  sides  of  the  bleeding  orifice.  If 
the  contusion  has  occurred  subcutaneously,  the  ulcerative  action  will 
allow  extravasation  into  the  muscular  and  cellular  tissues,  which,  if  ex- 
tensive, may  call  for  incision  into  the  tissues  and  ligation  of  the  vessel  at 
both  sides  of  the  wound,  for  ligation  above  the  seat  of  injury,  or  for 
amputation  of  the  limb. 

By  the  advent  of  inflammation  or  thrombosis,  a  bruised  artery  at  times 
becomes  obliterated  at  the  seat  of  contusion,  and  this  occlusion  may  give 
rise  to  gangrene  or  visceral  degeneration.  Aneurism  also  may  be  de- 
veloped after  contusion  of  an  artery. 

Slight  contusions  of  arteries  may  occur  without  marked  pathological 
consequences.  The  elasticity  of  the  vessels,  and  their  relations  to  sur- 
rounding parts  often  protect  them  from  such  violence. 

Arteries  may  be  torn  completely  asunder  subcutaneously  by  violent 
manipulation,  as  in  reducing  old  dislocations,  or  by  accidental  injuries. 
The  extravasation  which  follows  may  be  absorbed  as  the  torn  ends  of  the 
artery  become  sealed  by  obliterative  inflammation,  or  it  may  become  sur- 
rounded by  a  capsule  or  sac,  consisting  of  cellular  tissue  thickened  and 
condensed  by  pressure  and  inflammation.  The  extensive  character  of 
the  subcutaneous  bleeding  may  cause  violent  inflammation,  and  its  inter- 
ference with  the  peri})heral  circulation  may,  because  of  pressure,  lead  to 
gangrene.  Amputation  is  at  times  demanded  for  such  sequences  of 
arterial  rupture. 

Subcutaneous  extravasation  of  blood,  from  spontaneous  or  traumatic 
rupture  or  direct  wound  of  an  artery,  is  sometimes  termed  "  aneurism." 
The  term,  even  though  qualified  by  the  words  false  or  traumatic,  should 
be  rejected,  as  it  is  misleading  as  well  as  unscientific.  When  the  efi'used 
blood  becomes  encapsulated  and  the  communication  with  the  artery  per- 
sists, the  resemblance  to  aneurism  is,  however,  great.  Then  the  term  is 
not  altogether  inapplicable,  though  the  condition  is  not  strictly  an  aneurism 
but  an  arterial  hiematoma. 

Complete  laceration,  or  tearing  asunder,  of  an  artery  in  an  open  wound 
may  be  unattended  by  hemorrhage  because  of  the  twisting  and  tearing 
of  the  coats  at  the  time  of  injury.  It  is  well,  however,  to  ligate  such 
vessels  before  the  first  dressing  is  applied  if  they  are  seen  pulsating  in  the 
wound.  The  two  inner  coats  of  an  artery  are  sometimes  torn  in  subcu- 
taneous injuries,  while  the  external  tunic  by  reason  of  its  elasticity  re- 
mains intact.  This  partial  rupture  may  subsequently  become  complete 
by  the  giving  way  of  the  outer  coat,  and  be  followed  by  fatal  extravasa- 
tion. On  the  other  hand,  the  torn  coats  may  curl  up,  cause  coagulation 
within  the  vessel,  and  thus  lead  to  permanent  occlusion,  or  to  arrest  of 


WOUNDS    OF    ARTEKIES.  253 

circulation  and  consequent  gangrene.  Gangrene  may  arise  also  from  the 
torn  shreds  acting  as  a  valve  and  at  once  shutting  off  the  blood-flow  to 
the  parts  beyond.  Sometimes  the  injured  region  remains  as  a  weak  spot 
or  cicatrix  which  finally  becomes  the  seat  of  aneurism  due  to  a  traumatic 
cause. 

Fig.  98. 


Laceration  and  turning  backward  of  inner  coats  of  au  artery,  due  to  injury. 

(Bryant.) 

AVounds  of  arteries,  inflicted  by  sharp  instruments  or  spiculas  of  bone, 
may,  under  rare  circumstances,  involve  only  the  outer  and  part  of  the 
thickness  of  the  middle  coats.  Such  non-penetrating  wounds  give  rise  to 
no  primary  bleeding,  but  almost  invariably  are  followed  in  a  few  days  by 
secondary  hemorrhage.  Hence,  partial  penetration  of  arterial  walls, 
when  recognized,  should  be  treated  by  exposure  of  the  vessel,  ligation  on 
both  sides  of  the  wound,  and  complete  section  of  the  artery  between  the 
ligatures.  Penetrating  arterial  wounds,  unless  inflicted  by  very  fine 
needles,  are  followed  by  hemorrhage,  either  at  once  or  secondarily  from 
ulceration. 

The  amount  of  primary  bleeding  from  incisions  into  arteries  dej^ends 
on  the  direction  as  well  as  the  size  of  the  wound.  Transverse  wounds 
allow  more  gaping  and,  therefore,  more  bleeding  than  longitudinal  inci- 
sions. Oblique  cuts  hold  an  intermediate  position.  Complete  section  of 
an  artery  is  less  dangerous  in  this  respect  than  an  incision  involving  only 
a  portion  of  the  circumference,  for  the  former,  by  allowing  contraction 
and  retraction  of  the  coats,  affords  an  opportunity  for  spontaneous  arrest 
of  bleeding.  This  is  the  reason  that  when  cessation  of  bleeding  is  desired 
after  arteriotoray  of  the  temporal  artery  for  therapeutic  objects,  the 
surgeon  completely  divides  the  vessel.  Bleeding  may  at  once  cease  after 
the  division,  though  pressure  is  often  needed  in  addition.  If  this  section, 
moreover,  was  not  clone,  secondaiy  hemorrhage  or  traumatic  aneurism 
might  occur. 

Arterial  wounds  may  be  followed  by  death  from  external  or  internal 
hemorrhage,  or  may  cause  suppuration  or  gangrene  secondary  to  burrow- 
ing of  the  extravasated  blood  in  the  cellular  tissue.  The  tissues  may 
cicatrize  and  traumatic  aneurism  may  be  develojoed  as  a  result  of  arterial 
injury.  If  the  corresponding  vein  is  wounded  arterio-venous  fistula  may 
develop. 

Treatment. — The  treatment  of  arterial  wounds  in  the  limbs  should 
begin  by  resort  to  temporary  compression  by  means  of  a  rubber  bandage 
tightly  applied  above  the  wound.  The  arrest  of  bleeding  thus  obtaioed 
allows  opportunity  for  enlarging  the  wound  in  the  superjacent  structures, 
which  should  be  followed  by  ligation  of  the  vessel  on  both  sides  of  the 
Avound,  and  by  complete  division  of  the  artery  at  the  point  of  injury. 
Two  ligations  are  necessary  in  all  such  cases,  because  establishment  of  the 


254  INJURIES    AND    DISEASES    OF    ARTERIES. 

collateral  circulation  will  render  secondary  hemorrhage  from  the  distal 
part  of  the  artery  almost  certain.  Gunshot  wounds  of  arteries  recjuire 
similar  treatment. 

When  the  arterial  lesion  is  subcutaneous,  or  the  communication  with 
the  air  valvular,  or  when  the  superficial  tissues  have  healed  before  the 
partially  divided  vessel  has  given  way,  large  extra vjisation  and  burrowing 
of  blood  may  occur.  The  symptoms  are  :  Sudden  prostration  and  syncope 
from  the  anjiemia,  and  the  develo])ment  of  a  soft,  somewhat  elastic  and 
fluctuating  tumor,  with,  perhaps,  an  impulse,  thrill,  and  bruit  similar  to 
what  is  found  in  an  aneurism.  Pulsation  in  the  peripheral  vessels  may 
become  absent  and  the  limb  oedematous  and  of  low  temperature.  Pulsa- 
tion will  probably  not  appear  in  the  tumor  until  the  formation  of  a  cir- 
cumscribing cyst  wall  lias  begun.  This  difluse  extravasation  may  con- 
tinue increasing  until  death  results  or  gangrene  occurs.  Death  may 
supervene  by  rupture  and  a  discharge  of  blood  and  clots  into  some  cavity, 
or  from  the  skin  giving  way,  through  suppuration  and  ulceration,  and 
allowing  secondary  hemorrhage.  The  treatment  of  such  cases  of  arterial 
injury  consists  in  applying  pressure  to  the  artery  above  the  wound  and 
over  the  swelling,  keeping  the  patient  in  bed  and  the  limb  at  absolute  rest 
by  bandages  and  splints.  The  rubber  bandage  of  Esmarch  may  be  used 
temporarily  to  occlude  the  artery.  Ligation  of  the  trunk  at  some  distance 
above  the  swelling  so  as  to  be  above  the  first  branch  will  generally  succeed 
if  these  measures  be  inefficient.  When  it  is  impossible  to  obtain  ab.solute 
rest,  or  when  ligation  above  the  first  collateral  branch  is  inapplicable  or 
inefficient,  pressure  by  a  rubber  bandage  above  the  wound  must  be  made 
or  artificial  anaemia  by  the  Esmarch  method  obtained,  the  tumor  laid 
open,  the  clots  turned  out,  the  artery  completely  divided,  and  both  ends 
secured  bv  catgut  ligatures.  The  easiest  way  to  isolate  the  artery  is  to 
insert  a  probe  into  the  opening  and  then  dissect  the  vessel  free.  The 
ligature  can  then  be  readily  passed  around  it  by  means  of  a  curved  needle 
with  an  eye  near  the  point,  or  by  Horner's  curved  awl,  which  has  a 
shoulder  to  carry  a  loop  of  string  through  the  tissues  and  around  the 
vessel.     If  the  circulation  cannot  be  controlled   above  by  the  Esmarch 


Horner's  awl. 

apparatus,  the  surgeon  must  make  a  small  opening  in  the  skin  and  intro- 
duce one  or  two  fingers  of  the  left  hand  into  the  cavity  of  the  tumor. 
Thus  he  prevents  profuse  external  bleeding  by  having  the  cutaneous 
wound  plugged  with  the  fingers  with  which  he  feels  for  and  compresses 
the  arterial  wound.  After  getting  the  opening  in  the  artery  closed  by 
digital  pressure,  he  uses  the  right  hand  to  enlarge  the  skin  wound  and 
then  proceeds  to  turn  out  clots  and  ligate.  In  military  surgery  and  in 
special  cases  amputation  may  be  preferable  to  these  procedures. 

When  the  extravasation  is  comparatively  small  and  has  become  circum- 
scribed by  an  adventitious  sac  of  condensed  and  thickened  connective 
tissue,  laying  open  the  cyst  wall  and  tying  both  ends  of  the  artery  will 
often  be  quite  easily  performed,  and,  being  the  radical  operation,  is  prob- 


TRAUMATIC    ANEURISM.  255 

ably  more  judicious  than  ligation  of  the  artery  above  the  tumor.  In  the 
diffuse  and  profuse  extravasations  just  discussed,  ligation  above  the  first 
branch  is  probably  more  judicious  than  searching  for  the  arterial  wound 
among  the  structures  inundated  with  partially  coagulated  blood,  and  is 
certainly  better  than  ligation  immediately  above  the  injured  part  of  the 
artery.  This  position  of  the  ligature  is  usually  allowable  only  in  the 
small  extravasations,  where  there  is  little  danger  of  secondary  hemorrhage 
from  the  distal  part  of  the  vessel  when  the  collateral  circulation  is 
established. 

Surgical  interference  should  not  be  adopted  too  hastily  in  small  arterial 
extravasations,  especially  when  they  are  subcutaneous  or  due  to  fractured 
bones  injuring  the  artery. 

Spontaneous  cure  may  be  accompanied  by  the  contraction  of  the  con- 
densed cellular  tissue  and  coagulation  of  the  blood.  The  encysting  pro- 
cess, which  causes  the  development  of  an  adventitious  sac,  is  the  first  step 
in  such  cases.  Hence,  the  surgeon  should,  when  possible,  wait  until  he 
has  decided  that  nature's  efforts  at  cure  are  ineffectual. 

Traum atic  A neurism. 

Varieties. — Traumatic  aneurism  is  a  secondary  result  that  occasionally 
follows  arterial  injuries.  This  term  has  often  been  improperly  applied. 
It  should  be  restricted  to  the  following  conditions  : 

1.  Dilatation  of  the  cicatricial  tissue  and  adjacent  arterial  wall  after  a 
healed  penetrating  wound  of  an  artery. 

2.  Dilatation  and  hernial  protrusion  of  the  uninjured  inner  coats 
through  a  wound  of  the  outer  tissue  alone. 

3.  Dilatation  of  the  outer  tunic  after  an  injury  producing  rupture  of 
the  inner  coats  alone.  Such  ruptures  are,  as  a  rule,  produced  only  in 
vessels  whose  inner  coats  have  been  weakened  by  degenerative  changes, 
such  as  atheroma.  Hence,  such  cases  have  an  origin  which  often  makes 
the  terms  spontaneous  aneurism  and  traumatic  aneurism  equally  inappro- 
priate, since  two  causative  elements  are  present.  In  many  of  these  cases 
it  is  impossible  to  arrive  at  the  exact  cause,  from  either  the  clinical  history 
or  symptoms.  Fortunately,  these  are  the  very  instances  in  which  treat- 
ment is  very  little  influenced  by  the  character  of  the  cause. 

A  limited  exti^avasation  of  blood  from  puncture  of  one  of  the  smaller 
arteries  may  become  surrounded  by  an  adventitious  sac,  formed  by  inflam- 
matory condensation  and  thickening  of  the  normal  areolar  tissue.  This 
differs  somewhat  from  the  diffuse  and  burrowing  extravasation  spoken  of 
on  a  previous  page  under  wounds  of  artei'ies,  and  has  more  right  to  the 
title  "traumatic  aneurism."  Still  it  is  not  strictly  an  aneurism,  though 
it  is  a  blood  tumor  which  pulsates  and  has  a  thrill  and  bruit.  It  is  nothing 
but  an  encysted  extravasation  of  blood ;  or,  in  other  words,  an  arterial 
hsematoma. 

An  aneurism  is  a  circumscribed  dilatation  of  one  or  more  of  the  arterial 
coats,  induced  by  the  distending  influence  of  the  blood  current  upon 
abnormal  vascular  walls.  The  condition  being  discussed  having  no  such 
pathological  nature,  should  not  be  called  an  aneui-ism.  To  call  it  a 
"  false "  aneurism  would  be  illogical,  since  what  is  a  false  aneurism  is 
evidently  no  aneurism. 

Treatment. — The  proper  treatment  of  traumatic  aneurism  is  compres- 
sion of  the  artery  as  near  as  possible  to  the  sac  ;  or,  in  the  event  of  this 
procedure  failing,  ligation  in  the  same  situation. 


256 


ARTERIO- VKNOUS    WOUNDS    AND    FISTULES, 


Small  or  superficial  traumatic  aneurisms  may  be  treated  by  incision  of 
the  sac  and  ligation  of  the  artery  on  both  sides  of  it.  Dissection  of  the 
tissues  so  as  to  expose  the  sac  and  the  artery,  followed  by  ligation  on  both 
sides  without  opening  the  sac,  is  a  good  modification  of  the  same  method. 

The  different  methods  of  ligation,  described  in  the  section  on  the  treat- 
ment of  spontaneous  aneurism  as  Hunter's,  Wardroj)'s,  and  Brasdor's 
methods  may  sometimes,  on  account  of  the  location  of  the  tumor,  be 
preferable  to  ligation  immediately  above  the  sac. 

Arterio-venous  Wounds  and  Fistules. 

Definition  and  Pathology. — Puncture  or  gunshot  wounds  simul- 
taneously penetrating  an  artery  and  an  adjacent  vein  are  liable|to  be 
followed  bv  a  persistent  orifice  of  communication  between  the  two  blood- 
vessels. Such  fistulous  communications  which  may  form  slowly  have 
been  improperly  called  arterio-venous  aneurisms. 

When  the  lips  of  the  arterial  wound  remain  in  contact  with  and  become 
closely  adherent  to  those  of  the  adjacent  vein,  a  direct  fistulous  opening  is 
established  between  the  calibre  of  the  artery  and  that  of  the  vein.  When 
the  wall  of  the  vein  is  pushed  away  from  the  wall  of  the  artery  and  the 
extravasated  blood  burrows  between  them,  a  pouch  or  sac  is  developed, 
which  communicates  on  one  side  with  the  artery  and  on  the  other  side 
with  the  vein.  The  former  condition  has  been  termed  aneurismal  varix  ; 
the  latter  varicose  aneurism.     Neither  of  them  is  an  aneurism,  for  they 


Fig.  10(1. 


Fig.   101. 


First  form  of  arterio-venous  fistule. 
(Wyf.th.) 


Second  form  of  arterio-venous  fistule. 
(Wyeth.) 


are  not  circumscribed  dilatations  of  one  or  more  of  the  arterial  coats 
induced  by  the  distending  influence  of  the  blood  current  upon  abnormal 
vascular  walls.  Hence,  to  class  them  together  under  the  general  heading 
arterio-venous  aneurism  is  obviously  improper.  The  first  form  is  exhibited 
as  a  varicose  vein  or  varix,  with  pulsation  ;  and,  therefore,  mav.  per- 
haps with  some  degree  of  propriety,  be  called  an  aneurismal,  or  better,  an 
aneurismoid  varix.  The  second  form  is  in  the  development  of  its  adven- 
titious sac  identical  with  the  encysted  extravasation  or  arterial  hematoma 
described  on  page  252,  which  I  there  said  was  improperlv  termed  a  trau- 
matic aneurism.  Hence,  it  has  somewhat  more  right  to' be  classed  with 
aneurisms  than  the  first  form.  I  prefer  to  use  the  terms  simple  arterio- 
venous fistule.  and  sacculated  arterio-venous  fistule  to  describe  the  two 
forms  of  preternatural  arterio-venous  communication. 

Arterio-venous  fistules  of  both  kinds  very  occasionally  arise  without 
traumatism.  Ulceration  or  an  abscess  may  open  a  contiguous  arterv  and 
vein  and  permit  the  establishment  of  a  direct  or  indirect  orifice  of  com- 
munication. Again,  a  true  aneurism  may  cause  thinning  and  perfora- 
tion of  a  vein  upon  which    its  sac  presses.     In  this  case,  however,  the 


SIMPLE    AETERIO-VENOUS    FISTULE.  257 

condition  is  a  sequence  and  complication  of  aneurism,  not  a  ncAV  disease 
deserving  a  special  name. 

Simple  Arterio-venous  Fistule  or  Aneurismoid  Vctrix. 

Symptoms. — Aneurismoid  varix  is  a  dilated  condition  of  a  vein  due  to 
a  direct  fistulous  aperture  between  it  and  an  artery.  It  appears  as  a 
small,  soft,  bluish  tumor,  readily  disappearing  on  pressure,  which  is  the 
seat  of  a  peculiar  tremulous  jarring  or  vibratory  pulsation,  and  a  charac- 
teristic continuous  but  remittent  purring  murmur.  The  vibration  and 
murmur  are  due  to  the  injection  of  a  small  stream  of  arterial  blood  into 
the  vein  through  a  narrow  orifice  at  each  pulsation  of  the  artery.  This 
forcible  blood  current,  by  greatly  increasing  the  intravenous  pressure 
opposite  the  orifice  of  communication  and  by  antagonizing  the  upward 
flow  of  venous  blood,  causes  marked  distention  of  the  vein  at  the  site  of 
the  fistule,  and  leads  to  varicosity  of  other  veins  in  the  vicinity. 

The  vibration  and  murmur  may  be  transmitted  along  the  veins  to  a 
considerable  distance  from  the  opening ;  especially  is  this  the  case  in  an 
upward  direction.  The  swelling,  vibration,  and  murmur  are  lessened  by 
elevation  of  the  limb,  increased  by  its  being  placed  in  a  dependent  posi- 
tion. Digital  compression  of  the  vein  at  the  cardiac  side  of  the  tumor 
increases  these  phenomena,  but  similar  compression  on  the  distal  side 
exerts  no  influence  whatever.  Compression  of  the  artery  above  the 
swelling  causes  immediate  arrest  of  vibration  and  murmur,  which  are  at 
once  reestablished  upon  removal  of  pressure.  Pressure  upon  the  artery 
below  may  be  expected  to  increase  the  size  of  the  swelling. 

The  arterial  trunk  above  the  seat  of  disease  may  after  a  time  become 
enlarged  and  pulsate  more  vigorously  than  the  corresponding  vessel  of 
the  opposite  limb ;  but  below  the  aneurismoid  varix  the  artery  and  its 
branches  become  smaller  and  show  diminution  of  the  normal  pulsation. 
The  limb  below  the  disease  is  usually  weak  and  of  lower  temperature 
than  normal.  It  may  exhibit  a  hypertrophic  condition  of  the  skin,  nails, 
and  hair,  and  become  the  seat  of  oedema,  ulceration,  hemorrhage,  and 
perhaps  gangrene.  These  secondary  changes  are  due  to  interference  with 
the  normal  circulation. 

Aneurismoid  varix  of  the  scalp  is  sometimes  followed  by  such  a  gen- 
eral hypertrophy  of  the  venous  and  arterial  branches  that  a  mass  of  con- 
voluted and  pulsating  vessels  is  formed  which  cannot  be  distinguished 
from  arterial  varix,  the  so  called  cirsoid  aneurism. 

Simple  arterio-venous  fistule  or  aneurismoid  varix  is  usually  an  affec- 
tion of  slow  progress.  If  it  does  not  increase  nor  annoy  by  reason  of  its 
bulk  or  murmur,  it  requires  no  treatment. 

After  arterio-venous  punctures,  which  by  the  way  have  not  infrequently 
been  received  during  venesection  at  the  elbow,  the  possible  occurrence  of 
fistule  should  be  remembei'ed  and  an  attempt  to  prevent  such  a  sequence 
should  be  made  by  applying  pressure  to  the  wound  and  also  to  the  artery 
above  the  injury. 

Treatment — If  curative  treatment  is  deemed  necessary,  continuous 
digital  pressure  upon  the  tumor  directly  over  the  orifice  should  be  made. 

The  use  of  the  rubber  bandage  may  be  advantageous  if  so  applied  as 
to  stop  the  circulation  through  the  limb,  and  yet  leave  the  tumor  filled 
with  blood.  Coagulation  and  consequent  occlusion  of  the  orifice  may 
possibly  be  thus  effected.     Many  cases  will  resist  both  of  these  plans  of 

17 


258 


ARTERIO- VP:X0US    WOUNDS    AND    FISTULES. 


treatment.  Then  resort  to  ligation  is  justifiable  in  severe  cases  of  the 
diseiise.  The  artery  should  be  tied  above  and  below  the  opening  with 
catgut.  The  vein  should  be  carefully  separated  from  the  artery  at  the 
point  of  ligation  and  left  unmolested,  since  its  ligation  or  destruction 
greatly  increases  the  risk  of  gangrene  of  the  already  ]>oorly  nourished 
limb.  In  such  a  locality  as  the  thigh,  where  tlie  integrity  of  the  femoral 
vein  is  so  essential,  it  is  better  to  omit  phicing  the  lower  ligature  on  the 
artery  and  trust  to  elevation  of  the  limb  rather  than  to  endanger  the 
vein  by  rudely  endeavoring  to  separate  it  from  the  artery.  It  sometimes 
refpiires  great  care  during  the  operation  to  distinguish  the  thickened  and 
pulsating  veins  from  the  artery. 

Sacculated  Arferio  venous  Fistule. 

The  so-called  varicose  aneurism  is  not  an  aneurism,  but  is  a  sacculated 
arterio-venous  fistule,  diflJ'ering  from  the  aneurismoid  varix  or  simple 
arterio-venous  fistule  in  having  a  sac  or  pouch  between  the  artery  and 
vein,  from  which  there  is  one  opening  into  the  artery  and  another  into 
the  vein.  In  this  sac,  which  is  due  to  infiammatory  condensation  and 
thickening  of  the  normal  connective  tissue,  the  arterial  and  venous  blood 
currents  meet  and  intermingle. 

Fig.  102. 


Sacculated  arterio-venous  fistule.     (Erichsk.v.) 


Symptoms.^ — The  clinical  history  differs  from  that  of  simple  arterio-venous 
fistule  or  aneurismoid  vari.x;  in  having  certain  additional  .symptoms.  The 
same  venous  varicosity  exists  and  the  same  vibratory  or  jarring  motion,  and 
purring  murmur  are  present  in  the  veins,  though  less  marked  than  in 
aneurismoid  varix,  because  the  arterial  stream  is  not  forced  directly  into 
the  vein.  A  tumor  more  or  less  solid  can  often  be  perceived  lying  between 
the  two  vessels.  This  is  felt  to  be  the  seat  of  a  pulsation  synchronous  with 
the  arterial  pulsation  and  distinct  from  the  tremulous  jarring  of  the  dis- 
tended vein.  Auscultation  reveals  a  blowing  murmur,  like  that  of  a  true 
aneurism  which  is  additional  to  the  purring  murmur,  due  to  the  blood 
entering  the  vein.  (Edema,  cutaneous  hypertrophy,  ulceration,  and  other 
nutritive  changes  may  occur,  as  in  aneurismoid  varix.  The  sacculated 
arterio-venous  fistule  diflfers  from  the  simple  in  its  greater  tendency  to  be 
progressive ;  and,  by  the  distention  and  enlargement  of  the  sac,  to  lead 
to  sloughing  of  the  skin  and  fatal  hemorrhage.  The  sac,  as  a  rule,  grad- 
ually becomes  somewhat  hard  from  internal  fibrous  deposition,  and,  indeed, 
this  process  occasionally  causes  spontaneous  closure  of  the  venous  open- 
ings and  simplifies  the  treatment  of  the  disease.  The  progressive  char- 
acter of  the  condition  is  such  that  treatment  is  nearly  always  demanded. 

Treatment. — Means  to  obliterate  the  sac  should   usuallv  be  under- 


INFLAMMATORY    CHANGES    IX    ARTERIES.  259 

taken  if  the  diagnosis  from  aneurismoid  varix  has  been  established.  This 
differential  diagnosis  at  times  may  be  difficult.  Digital  or  instrumental 
compression  of  the  artery  above  the  disease,  combined  with  pressure  di- 
rectly upon  the  opening  into  the  vein,  should  be  the  first  resort.  A  similar 
method  is  to  apply  the  rubber  bandage  tightly  from  the  fingers  or  toes 
up  to  the  tumor,  to  carry  it  with  only  moderate  pressure  over  the  tumor 
and  finally  to  constrict  the  limb  tightly  above  the  seat  of  the  disease. 
Thus  the  sac  is  left  full  of  blood  which,  by  the  arrest  of  circulatory 
movement,  is  given  an  opportunity  to  coagulate  and  thus  induce  oblitera- 
tion of  the  sac  and  closure  of  the  fistulous  apertures.  Pressure,  if  it  does 
not  cause  a  radical  cure,  may  at  least  close  the  venous  opening  and  thus 
reduce  the  lesion  to  a  more  simple  and  manageable  condition. 

When  pressure  fails,  ligation  of  the  artery  immediately  above  and  below 
the  sac  is  the  proper  procedure.  The  coats  are  usually  healthy,  since  the 
condition  is  due  in  nearly  every  instance  to  a  wound.  Hence,  the  ligatures 
can  be  applied  near  the  seat  of  disease.  The  neck  of  the  sac  also,  if 
accessible,  may  be  tied  close  to  the  artery.  AVhen  the  shrunken  lower 
part  of  the  artery  cannot  be  found,  it  may  become  necessary  to  lay  open 
the  sac.  A  probe  can  then  usually  be  passed  down  the  vessel  through 
the  aperture  connecting  the  sac  with  the  calibre  of  the  artery.  In  such 
operations  it  must  be  remembered  that  if  the  vein  is  first  laid  open,  the 
surgeon  sees  only  the  venous  opening  into  the  sac.  A  second  incision  is 
then  required  to  open  the  sac  and  disclose  the  arterial  orifice.  Care  should 
be  exercised  to  avoid  tying  or  tearing  the  main  veins  of  the  limb.  Such 
a  complication  adds  to  the  risk  of  gangrene.  When  such  venous  inter- 
ference is  unavoidable  in  old  and  feeble  patients,  amputation  will  prob- 
ably be  preferable  to  the  double  ligation.  In  all  these  operations  the 
rubber  bandage  should  be  applied  as  a  preparatory  step. 

Coagulating  injections  into  the  sac  after  immobilizing  the  blood  by  an 
elastic  bandage  have  been  suggested.  The  method  by  ligation  is  prob- 
ably less  dangerous,  and  at  the  same  time  more  radical  in  priiici^jle. 

Arteritis  and  Degenerative  Changes  in  Arteries. 

Pathology. — Inflammation  of  arterial  walls,  if  acute,  usually  involves, 
sooner  or  later,  the  three  coats ;  but  the  pathological  changes  may  begin 
or  become  more  marked  in  any  one  of  the  tunics.  Hence,  we  have  the 
terms  endarteritis,  mesarteritis,  and  periarteritis  expressing  inflammation 
of  the  inner,  middle,  and  outer  coats  respectively.  Chronic  arteritis 
affects  principally  the  inner  coat.  Arteritis  is  caused  by  external  or  in- 
ternal violence,  such  as  wounds  or  lodgement  of  emboli ;  by  extension  of 
inflammation  from  surrounding  tissues,  as  in  phagedena  ;  and  by  the  con- 
stitutional states  that  induce  impaired  nutrition,  such  as  syphilis,  rheum- 
atism, gout,  alcoholism,  and  renal  disease.  The  results  that  may  follow 
arteritis  are  fatty  degeneration,  atheroma,  and  calcification  of  the  tunics ; 
occlusion  or  aneurismal  dilatation  of  the  calibre  of  the  vessel ;  and  sup- 
puration, ulceration,  or  perforation  of  the  vascular  wall.  The  organs 
and  structures  supplied  by  the  inflamed  artery  may  suffer  by  loss  of  func- 
tion and  become  the  seat  of  gangrene  secondarily  to  these  sequences  of 
arteritis. 

The  pathological  changes  found  in  traumatic  arteritis  are  similar  in 
character,  whether  they  begin  externally  or  internally.  The  inflammatory 
process  commences  in  the  tunic  injured,  but,  as  a  rule,  soon  spreads  to  the 


2t)0  INFLAMMATION    OF    ARTERIES. 

other  coats.  Internal  violence,  such  as  is  produced  by  the  inii)inging  of 
the  blood-current  or  by  the  impact  of  an  embolus,  is  more  apt  to  induce 
an  intlanimation  limited  to  one  tunic  than  is  external  violence,  which 
usually  injures  all  coats  siinultaneously. 

Traumatic  arteritis  from  external  causes  must  necessarily  be  accom- 
panied by  contusion,  laceration,  or  some  such  complicating  lesion  of  the 
periarterial  structures. 

The  j)athological  alterations  seen  in  arteritis  are  very  like  those  which 
have  been  detailed  as  occurring  in  phlebitis.  The  external  tunic  of  the 
artery  becomes  unusually  va.scular,  and  is  swollen  from  infiltration  by 
serum  and  white  corpuscles  that  have  migrated  out  of  the  vasa  vasorum. 
These  changes  cause  thickening  and  softening.  The  middle  and  internal 
coats  also  are  thickened  and  softened  and  the  site  of  cell  proliferation. 
The  internal  tunic  loses  its  smooth,  glistening  appearance,  is  elevated  in 
patches  which  are  sometimes  the  seat  of  erosions,  and  usually  becomes 
pinkish  in  color.  The  calibre,  or  lumen,  of  the  vessel  is  lessened  by  the 
swelling  of  the  coats,  the  projection  inward  of  the  inner  tunic,  and  prob- 
ably also  by  spasm  of  the  inner  coat.  When  there  is  rupture  of  the  in- 
ternal tunic,  as  happens  in  ligations  and  other  injuries,  there  will  be  more 
encroachment  and  even  occlusion  of  the  lumen,  for  the  roughened  and 
projecting  margins  will  cause  fibrinous  deposition.  The  formation  of  a 
coagulum  consisting  of  white  corpuscles  and  fibrin  occurs  in  arteritis  as 
in  phlebitis,  though  less  often,  even  without  previous  rupture  of  the  inner 
coat.  It  is  much  more  unusual  in  acute  than  in  chronic  arteritis.  In 
syphilitic  arteritis  it  is  not  infrequent.  As  in  phlebitis  the  thrombosis  is 
at  times  the  cause,  at  others  the  result,  of  arteritis. 

When  complete  occlusion  of  the  artery  and  arrest  of  the  blood-current 
are  produced  by  the  pushing  inward  of  the  internal  coat  and  by  the  depo- 
sition of  cells  and  fibrin,  permanent  obliteration  of  the  vessel  may  take 
place  from  organization  of  the  cells  of  the  coagulum  as  was  formerly 
believed,  or  from  organization  of  the  newly-formed  tissue  springing  from 
the  normal  cells  of  the  internal  coat.  There  occurs  thus  a  species  of 
cicatricial  contraction  which  converts  the  former  arterial  tube  into  an 
impervious,  fibrous  cord.  Sometimes,  however,  the  clot,  on  the  other 
hand  undergoing  fatty  degeneration,  is  washed  away  as  minute  particles 
of  fat  which  do  no  harm,  and  the  artery  regains  its  normal  patulous  con- 
dition. Sometimes  fragments  of  the  clot  are  detached,  and  as  emboli  are 
carried  onward  until  they  plug  some  distant  artery  of  smaller  calibre. 
There  they  may  be  absorbed  or  may  produce  local  antemia  and  infarction. 
At  other  times  disintegration  of  the  primary  coagulum  occurs,  due  to 
septic  or  pyogenic  bacteria,  and  septicseraia  or  multiple  infective  embolism 
and  pysemia  may  result. 

When  suppuration  and  ulceration  occur,  as  happens  at  times  in  septic 
traumatic  arteritis,  there  is  great  liability  of  perforation  and  hemorrhage 
unless  the  previous  occlusion  of  the  artery  by  a  coagulum  has  been  com- 
plete. Suppuration  in  the  outer  coat  is  generally  diffuse,  but  in  the 
middle  tissue  it  may  be  localized  as  distinct  abscesses.  Pyiemic  infarction 
is  readily  induced  if  septic  material  from  suppuration  of  the  vascular 
walls  or  of  the  surrounding  structures  gains  entrance  to  the  blood  current. 
The  hyperplasia  of  connective  tissue,  which  may  take  place  in  the  middle 
coat  as  a  sequence  of  arteritis,  causes  atrophy  of  the  muscular  and  elastic 
fibres,  and  renders  the  vessel  less  able  to  resist  the  distending  influence  of 
blood  pressure  ;  hence,  subsequent  aneurismal  dilatation  may  occur  at  the 
seat  of  the  former  arterial  inflammation.     Infective  emboli,  causing  acute 


DEGENERATIVE    CHANGES    IN    ARTERIES,  261 

inflammation    and   softening,  are  believed   to  be   a   frequent   cause   of 
aneurism  when  occurring  in  the  young. 

Idiopathic  arteritis  is  usually  associated  with  and  a  result  of  inflammation 
of  the  structures  surrounding  the  vessel,  unless  it  be  due  to  syphilis,  gout,  or 
some  similar  dyscrasia.  Many  cases  denominated  idiopathic  arteritis  are 
really  instances  of  traumatic  inflammation,  caused  by  the  imjDact  of  the 
blood  current,  or  of  emboli  from  cardiac  vegetations  against  the  internal 
arterial  coat.  Such  are  the  cases  of  endarteritis  and  resulting  fatty  degen- 
eration not  infrequently  found  at  the  great  sinus,  the  transverse  arch  and 
the  bifurcation  of  the  aorta,  and  in  the  innominate  artery.  Idiopathic 
arteritis  presents  pathological  changes  similar  to  those  seen  in  traumatic 
cases. 

Syphilitic  arteritis  is  a  chronic  inflammation,  and  occurs  especially  in 
the  smaller  arteries.  The  vessels  of  the  brain  are  particularly  liable  to  it, 
and  on  account  of  the  resulting  circulatory  interference  the  disease  is  a 
serious  one  in  this  locality.  Aneurism  may  be  due  to  syphilitic  arteritis 
of  the  aorta  and  larger  vessels.  The  pathological  changes  arise  chiefly  in 
the  internal  tunic,  which  by  reason  of  the  inflammatory  proliferation  of 
cells  projects  into  the  lumen  or  calibre  of  the  vessel,  and  causes  great  nar- 
rowing or  complete  occlusion  of  the  blood  channel.  Death  from  cerebral 
anaemia  thus  induced  is  not  very  infrequent.  It  is  often  impossible  dur- 
ing life  to  diagnosticate  syphilitic  arteritis  from  atheroma.  In  fact,  both 
diseases  may  exist  at  the  same  time.  Atheroma  is  more  common  in  the 
old  than  the  young,  and  causes  arterial  weakening  and  dilatation  rather 
than  occlusion.  Atheroma  is  not  so  apt  to  attack  the  smaller  vessels  as 
is  syphilis.  After  death  microscopic  examination  shows  that  atheroma 
has  a  greater  tendency  to  involve  all  the  coats  than  syphilis,  which  is 
usually  more  or  less  limited  to  the  internal  coat. 

Rheumatic  arteritis  is  said  to  be  rare.  That  it  has  not  been  studied  as 
carefully  as  the  other  forms  may  be  the  reason  for  this  supposition. 
Rheumatic  inflammation  of  the  lining  membrane  of  the  heart,  which  is 
similar  to  the  lining  coat  of  arteries,  is  certainly  common.  Mechanical 
strain  put  upon  the  coats  of  the  vessel  by  reason  of  increased  or  unusual 
intravascular  pressure  is  a  cause  of  chronic  arteritis.  These  chronic 
forms  of  arteritis  are  all  allied  to  degenerative  processes,  and  have  few  well- 
marked  symptoms. 

Symptoms. — The  symptoms  of  arteritis,  when  more  or  less  acute,  and 
the  accompanying  thrombosis  are  severe  pain,  tenderness  and  hyper- 
esthesia in  the  course  of  the  vessel  and  in  the  parts  supplied  by  it,  and 
impairment  of  muscular  power.  This  pain  may  resemble  rheumatism. 
The  surface  temperature  is  lowered,  and  the  skin  perhaps  mottled.  When 
the  vessel  is  superficial,  a  hard,  pulseless  cord  may  be  felt  or  seen  through 
the  skin  ;  if  only  partial  occlusion  has  taken  place,  a  jerky  pulse  may  be 
perceptible.  Secondary  gangrene,  with  its  characteristic  symptoms,  may 
arise  from  the  interruption  of  circulation,  especially  in  the  old  and  feeble. 

Treatment. — The  treatment  of  arteritis  consists  in  rest,  wrapping  up 
the  limb  in  cotton  to  maintain  heat,  administering  opium  to  relieve  pain, 
and  using  tonics,  stimulants,  and  good  food  to  prevent  depression.  As 
gangrene  is  a  not  unusual  sequence,  the  husbanding  of  vital  resources  is 
required.  This  precludes  the  use  of  depressants  in  the  early  stages,  unless 
the  patient  is  unusually  vigorous  and  the  disease  so  situated  as  to  render 
subsequent  gangrene  limited.  Measures  to  obviate  gangrene  and  to 
avert  fatal  hemorrhage  from  ulcerative  perforation  are  to  receive  careful 
consideration.     Syphilitic,  rheumatic,  gouty,  and  other  forms  of  arteritis 


262  DISEASES    OF    THE    ARTERIES. 

should  be  treated  with  mercury,  iodide  of  potassium,  alkalies,  salicylic 
acid,  colchicum,  etc.,  with  a  view  both  of  preventing  further  progress  and 
of  perhaps  effecting  cure.  Microbic  invasion  of  wounds  must  be  pre- 
vented by  rigid  asepsis  and  antisepsis,  since  it  has  been  shown  that  septic 
discharges  are  the  chief  cause  of  ulcerative  and  suppurative  arteritis. 

Athekomatou!^    Degenkration    and  Calcification    of    Arteries. 

Any  form  of  chronic  arteritis  may  terminate  in  atheromatous  degenera- 
tion of  the  vascular  walls.  This  condition  is  due  to  rnalnutrition  of  the 
arterial  tunics,  and  is  a  fatty  degeneration  of  their  cellular  elements.  It 
occurs  as  a  secondary  lesion  following  chronic  inflammation  of  arteries, 
and  is  fre(|uently  found  in  syphilitic  and  senile  subjects.  It  differs  from 
the  primary  and  localized  fatty  change  belonging  to  the  pathology  of 
endarteritis  in  being  a  secondary  lesion,  which  affects  the  arteries  gen- 
erally, and  which  is  liable  to  give  rise  to  thrombosis,  embolism,  and 
hemorrhage.  The  destructive  process,  moreover,  causes  infiltration  not 
only  of  the  inner  coat,  but  also  of  the  muscular  and  elastic  coats,  trans- 
forming the  normal  elements  into  granular  material.  Atheromatous 
degeneration  is  seen,  on  examination  of  the  inner  surface  of  the  vessel 
wall,  as  numerous  definitely-outlined,  soft,  pulpy  patches,  which  are  scat- 
tered throughout  the  arterial  system.  The  pulpy  material  found  in  the 
centre  of  these  softened  spots  gives  the  name  atheroma  to  this  peculiar 
molecular  destruction,  and  under  the  microscope  is  found  to  consist  of 
f^itty  and  granular  matter,  mingled  with  cholesterin  crystals  and  shreds 
of  fibrous  tissue.  The  middle  coat  soon  becomes  infiltrated  with  fatty 
particles,  and  the  outer  one  also  undergoes  degeneration. 

The  weakening  of  the  vascular  wall  may  allow  the  blood  pressure  to 
cause  aneurismal  dilatation  or  ru{)ture.  The  softening  of  the  deep  layers 
of  the  internal  coat  may  give  rise  to  the  so-called  atheromatous  abscess  ; 
if  the  superficial  layer  is  destroyed  the  atheromatous  ulcer  remains. 

At  times  calcereous  degeneration  of  the  tunics  occurs  as  a  secondary 
and  conservative  process,  as  if  nature  was  endeavoring  to  counteract  the 
effect  of  the  softening  influences  of  atheroma.  Calcification  is  more  fre- 
quent when  the  atheromatous  change  is  slowly  progressing,  and  the  two 
processes  may  be  going  on  together  at  the  same  time  in  the  same  locality. 
The  chalky  change  begins  in  the  inner  and  middle  coats,  but  the  entire 
vessel  wall  may  be  converted  into  a  calcareous  cylinder,  though  isolated 
plates  of  calcification  are  much  more  common.  By  the  washing  away  of 
the  pulpy  or  atheromatous  material  on  the  inner  surface  the  calcareous 
plates  may  be  uncovered  ;  and  sometimes  the  blood  current  gains  entrance 
beneath  the  chalky  portion  of  the  wall,  and  by  a  species  of  dissection 
separates  the  tunics,  or  their  different  layers,  and  thus  creates  the  so-called 
aneurism  by  dissection. 

The  atheromatous  and  calcific  degeneration  causes  arteries  to  become 
brittle  and  inelastic  and  roughened  on  the  interior  and  exterior,  and  thus 
predisposes  to  loss  of  function  and  rupture,  by  which  hemorrhage,  occlu- 
sion, and  gangrene  may  arise.  It  is  a  common  senile  change,  and  is  par- 
ticularly liable  to  occur  in  the  arteries  of  the  brain  and  in  the  main 
arteries  of  the  trunk  and  limbs.  It  is  not  uncommon  as  a  ring  about  the 
root  of  a  large  branch.  Ligation  of  such  diseased  vessels  is  apt  to  be 
followed  by  secondary  hemorrhage  from  the  ligature  cutting  through  the 
brittle  walls.     A  broad,  flat  ligature  to  produce  mere  apposition  of  the 


ANEURISM.  263 

arterial  walls  is  proper  under  such  circumstances.  The  weakening  of  the 
middle  coat  induced  by  atheroma  is  a  frequent  precursor  of  spontaneous 
aneurism. 

Some  writers  believe  that  the  calcareous  degeneration  of  arteries  in  the 
aged  is  not  secondary  to  atheroma,  but  is  a  primary  change,  and  occurs 
in  the  middle  coat  first;  while  that  secondary  to  atheroma  begins  in  the 
internal  coat. 

True  ossification  of  arteries  seldom,  if  ever,  occurs.  Cases  so  denomi- 
nated are  probably  instances  of  calcification.  Tiiese  degenerative  changes 
cannot  be  arrested  by  any  special  line  of  treatment.  The  indications  are 
to  keep  up  nutrition,  to  avoid  severe  exercise,  which  causes  increased 
blood  pressure  in  the  brittle  arteries,  and  to  perform  none  but  necessary 
operations,  because  of  the  imperfect  circulatory  supply  and  the  tendency 
to  secondary  hemorrhage. 

Aneurism. 

Definition. — An  aneurism,  strictly  defined,  is  a  circumscribed  dilata- 
tion of  one  or  more  of  the  arterial  coats,  induced  by  the  distending  in- 
fluence of  the  blood  current  upon  abnormal  vascular  walls. 

This  definition  properly  excludes  : 

1.  General  dilatation  with  elongation  of  an  artery  (often  called  cirsoid 
aneurism,  varicose  artery,  arterial  varix). 

2.  General  dilatation  of  small  arteries  and  of  capillaries  (often  called 
aneurism  by  anastomosis). 

3.  Arterial  venous  fistule  (usually  called  arterio- venous  aneurism). 

4.  Separation  of  the  arterial  tunics  by  the  blood  current  (usually  called 
dissecting  aneui'ism). 

5.  Extravasation  of  arterial  blood  due  to  spontaneous  rupture  (one  of 
the  forms  of  so-called  false  aneurism). 

6.  Extravasation  of  arterial  blood  due  to  wounds  and  injuries  (called 
by  some  writers  a  form  of  traumatic  aneurism ). 

These  widely  different  pathological  conditions  often  receive,  though 
improperly,  the  name  aneurism  because  they  are  tumors  containing  blood 
or  blood-clots.  They  are  not  aneurisms  according  to  the  definition  that  I 
have  given,  and  as  they  present  symptoms  and  require  treatment  different 
from  aneurism  I  have  discussed  them  in  their  appropriate  places  else- 
where. 

Varieties. — If  the  conditions  mentioned  above  be  excepted,  there  are 
only  two  forms  of  aneurism — the  tubular  or  fusiform  and  the  sacculated 
or  sacciform. 

Separation  of  arterial  coats,  which  occurs  at  times  as  a  result  of  arter- 
itis by  the  blood  insinuating  itself  between  the  layers  of  the  middle  tunic 
or  between  the  inner  tunic  and  the  middle,  is,  under  the  name  "  dissect- 
ing "  aneurism  accepted  by  most  writers  as  a  form  of  aneurism.  I 
prefer,  however,  to  reject  it,  since  it  diflers  from  aneurism  in  every  essen- 
tial feature.  It  occurs  chiefly  in  the  aorta,  which  may  show  the  separation 
through  nearly  its  entire  length.  The  blood  current  may  separate  the 
coats  for  a  long  distance  or  form  a  circumscribed  sac  within  the  thick- 
ness of  the  arterial  wall.  The  blood  may  finally  burst  through  the  outer 
surface  of  the  w-all,  and  cause  hemorrhage  into  the  cellular  tissue,  or  into 
the  pericardial,  pleural,  or  abdominal  cavity.  Sometimes  the  diverted 
current  re-enters  the  calibre  of  the  vessel  through  an  opening,  due,  as 
was  the  opening  of  exit,  to  a  patch  of  atheromatous  softening.     This  tun- 


264 


DISEASES    OF    THE     ARTERIES, 


Fig.  1();{. 


nel-like  channel,  witli  the  consetjuent  thickening  of  tlie  vessel  wall,  may 
cause  the  artery  to  present  the  appearance  of  being  double.  It  would  be 
possible  for  the  separated  coats  to  bulge  into  the  calibre  of  the  artery,  and 

by  occlusion  cause  gangrene  of  the  parts 
below.  It  is  readily  seen  that  this  separa- 
tion of  arterial  coats  is  very  different  from 
aneurism,  and  only  corresponds  to  the  defi- 
nition of  aneurism  when  a  distinct  circum- 
scribed sac  is  formed  within  the  thickness 
of  the  vessel  wall.  This  is  of  exceedingly 
rare  occurrence.  It  is,  therefore,  better  to 
limit  the  term  aneurism  to  the  two  forms, 
tubular  and  sacciform,  and  dismiss  the  term 
dissecting  aneurism  entirely,  using  instead 
the  words  separation  of  arterial  coats. 

A  fusiform  or  spindle-shaped  aneurism  is 
a  dilatation  or  expansion  of  the  entire  cir- 
cumference, and  usually  of  all  the  coats  of 
an  artery,  while  a  sacciform  aneurism  is  a 
sac  or  pouch  consisting  of  one  or  more  of 
the  coats  developed  upon  one  side  of  the 
artery,  and  communicating  with  the  interior 
of  the  vessel  by  a  narrow  opening. 

Fusiform  aneurism  is  much  less  common 
than  the  sacciform  variety,  and  is  chiefly 
met  with  in  the  aorta,  and  in  the  iliac  and 
femoral  arteries.  The  dilatation,  though 
not  always  uniform,  is  usually  more  marked 
at  the  middle  of  the  tumor  and  diminished 
toward  each  extremity  until  the  normal 
calibre  of  the  artery  is  regained.  This  gives 
the  aneurism,  which  necessarily  has  an 
opening  of  entrance  and  one  of  exit,  a  spindle  shape.  The  walls  of  the 
tumor  consist  of  degenerated  and  thickened  arterial  coats  with  a  rough- 
ened inner  surface.  There  is  some  increase  in  the  length  of  the  artery 
at  the  dilated  and  hypertrophied  spot.  This  form  of  aneurism,  unlike 
the  sacciform  variety,  does  not,  as  a  rule,  enclose  laminated  fibrine. 
Chronic  arteritis  with  its  consequent  atheromatous  degeneration  of  the 
arterial  walls  is  the  chief  factor  in  the  causation  of  such  aneurisms. 
Traumatic  fusiform  aneurism  seems  to  me  to  be  almost  an  impossibility. 
Occasionally  several  fusiform  aneurisms  are  developed  in  connection  with 
the  same  artery,  which  is  of  normal  calibre  between  the  dilated  regions. 
The  lateral  blood  pressure  in  fusiform  aneurisms  is  comparatively  mod- 
erate in  amount ;  hence  they  grow  slowly  and  do  not  readily  burst ;  but 
it  is  not  unusual  for  a  sacciform  aneurism  to  be  developed  upon  the  sur- 
face of  a  fusiform  dilatation  and  to  cause  death  by  rupture.  In  cases 
of  very  large  fusiform  aneurism  of  the  aorta  death  may  also  occur  from 
syncope,  because  the  heart  is  unable  to  give  sufficient  forward  motion  to 
the  mass  of  blood  contained  in  the  large  tumor.  Hence  the  circulatory 
movement  in  the  more  distant  vessels  is  impaired  and  fatal  syncope  may 
supervene. 

The  sacciform  aneurism  is  the  most  common  variety  of  the  disease,  and 
is  that  which  is  meant  when  the  simple  term  "aneurism  "  is  used.  Fusi- 
form aneurisms  are  so  infrequent,  and  in  comparison  with  the  sacciform 


Diagram  showing  separation 
of  arterial  coats,  often  called  dis- 
secting aneurism. 


ANEURISM, 


265 


Fig.  104. 


variety  so  unimportant  surgically,  that  I  shall  scarcely  refer  to  them 
again.  My  subsequent  remarks,  therefore,  will  refer  to  sacciform  dilata- 
tion of  arteries. 

A  sacciform  aneurism  is  a  sac  or  pouch  developed  upon  one  side  of 
an  artery  by  localized  dilatation  of  the  arterial  wall  and  communicating 
with  the  interior  of  the  vessel  by  a  narrow  orifice  or  mouth.  The  cavity 
of  the  sac  has  a  much  greater  diameter  than  its  orifice  of  communication 
with  the  artery,  and  it  is,  therefore,  usual  to  speak  of  the  body,  neck,  and 
mouth  of  the  aneurism.  The  walls  of  the  sac  may,  if  the  tumor  is  small, 
consist  of  all  three  arterial  tunics ;  but  usually  it  is  only  the  outer  tunic, 
and  perhaps  part  of  the  thickness  of  the  middle  tunic  that  form  the  sac. 

As  internal  pressure  causes  further  distention,  the  tunics  become  blended 
and  finally  may  disappear  at  places  and  be  substituted  by  an  adventitious 
wall  of  condensed  and  newly-formed  cellular  tissue. 
Sacciform  aneurism  may  be  developed  upon  the  sur- 
face of  a  fusiform  aneurism,  which  is,  as  has  been  seen, 
little  more  than  a  diseased  and  greatly  enlarged  ar- 
tery. 

Causes. — Any  agency  that  lessens  the  power  of 
the  artei'ial  wall  to  resist  the  stretching  influence  of 
the  blood  impelled  by  the  cardiac  impulse,  and  any 
circumstance  that  diminishes  that  normal  elasticity  by 
which  the  artery  contracts  as  soon  as  this  stretching 
influence  is  relaxed  must  predispose  to  aneurismal 
dilatation.  Hence  the  degenerative  fatty  change 
known  as  atheroma,  which  occurs  in  the  arterial 
tunics  as  a  result  of  arteritis,  is  the  chief  factor  caus- 
ing a  predisposition  to  aneurism.  Anything  that  in- 
duces the  atheromatous  change,  such  as  advancing 
age  and  alcoholic  intemperance,  may  be  an  indirect 
cause  of  aneurism.  Unusual  muscular  exertion,  by 
inducing  violent  heart  action  and  preventing  rapid 
admission  of  blood  into  the  capillaries,  causes  in- 
creased intravascular  pressure,  and  thus  may  be  the 
immediate  cause  of  an  aneurismal  dilatation  If  the  artery  is  previously 
atheromatous  the  sudden  strain  causes  the  inner  coat  to  give  way  at  a 
point  where  an  atheromatous  patch  is  situated ;  the  fatty  pulp,  lying 
under  the  inner  layer  of  the  inner  tunic,  is  evacuated,  and  thus  in  the 
integrity  of  the  wall  a  breach  is  made  which  allows  distention  to  occur 
under  the  force  of  the  bloodr^ stream.  Continuously  laborious  occupation 
is  not  so  dangerous  in  this  regard,  for  the  vessels  seem  to  acquire  strength 
by  the  gradual  accession  of  great  intravascular  tension.  It  is  a  sudden 
strain,  in  vessels  unused  to  such  a  degree  of  tension,  and  which  are  pre- 
viously degenerated,  that  tends  to  cause  such  damage. 

External  violence  without  a  wound,  such  as  blows  and  concussions,  may 
loosen  the  membrane  covering  an  atheromatous  spot  and  induce  aneurism 
in  much  the  same  way.  Internal  strain  upon  the  arterial  walls  is  in- 
creased by  postures  which  cause  flexures  of  the  vessel ;  by  over-tight 
clothing,  especially  around  the  neck ;  and  by  the  anatomical  division  of 
the  artery  into  two  branches  of  nearly  equal  calibre.  The  blood-flow  is 
retarded  by  these  conditions,  and  consequently  the  lateral  pressure  is  in- 
creased. Hence,  aneurism  is  more  liable  to  occur  when  sudden  muscular 
efl^ort  is  made  or  any  unusual  strain  is  thrown  upon  the  walls  of  an  artery 
under  such  disadvantageous  circumstances.     Sometimes  a  "  giving  way  " 


Sacciform  aneurism 
from  injury.  The  ar- 
tery laid  open  to  show 
opening  into  sac. 
(Bryant.) 


26fi  DISEASES    OF    THE    ARTERIES. 

sensation  is  felt  at  the  time  of  the  violent  exertion.  This  is  probably 
caused  by  a  rupture  of  the  middle  coat,  and  may,  perhaps,  occur  in  a 
healthy  artery. 

There  appears  to  be  an  imperfectly  understood  connection  between  heart 
disease  and  the  occurrence  of  aneurism.  Embolism  is  believed  by  some 
authors  to  cause  the  development  of  aneurismal  dilatation.  This  is  espe- 
cially so  in  infective  embolism  from  ulcerative  endocarditis  and  other 
septic  processes.  As  the  aneurism  occurs  at  and  not  above  the  point  of 
lodgement  of  the  embolus,  the  lesion  is  supposed  to  be  due  to  a  local 
arteritis  resulting  from  the  septic  character  of  the  embolus.  This  is  the 
e.xplanation  of  the  well-known  non-occurrence  of  aneurism  in  cases  of 
non-infective  embolism. 

Syphilis  has  been  regarded  by  some  writers  as  a  cause  of  aneurism. 
This  is  doubtful,  since  sy])hilitic  arteritis  seldom  attacks  the  larger 
arteries,  and  it  is  here  that  aneurism  is  more  commonly  met.  It  is  pre- 
eminently a  disease  of  small  vessels.  I  am,  of  course,  speaking  now  of 
surgical  aneurism,  not  of  aneurism  of  arteries  of  the  brain.  Finally, 
wounds  of  arteries  may  be  followed  by  aneurism.  The  subject  of  trau- 
matic aneurism  has,  however,  been  discussed  in  a  previous  section,  and 
recjuires  no  further  mention  here. 

When  an  atheromatous  spot  has  given  way,  as  described  above,  and  the 
])ressure  does  not  cause  complete  perforation  of  the  wall  and  hemorrhage, 
it  is  usually  a  sacciform  aneurism  that  is  developed.  When,  however, 
there  is  an  absence  of  normal  and  of  inflammatory  adhesion  between  the 
tunics  and  their  component  layers,  separation  of  the  arterial  coats  may 
be  induced  by  the  blood  current  insinuating  itself  between  them.  Thus 
may  be  caused  on  rare  occasion  separation  of  the  arterial  coats,  the  so- 
called  dissecting  aneurism. 

PATHOLO(iY. — Dissection  of  a  sacculated  aneurism  shows  on  the  out- 
side an  investment  or  covering  of  cellular  tissue,  resulting  partly  from 
inflammatory  condensation,  partly  from  atrophy  of  the  muscles  and  other 
structures  that  have  been  subjected  to  pressure  by  the  increasing  tumor. 
Within  this  more  or  less  imperfect  investment  is  found  the  true  aneurismal 
sac,  consisting  of  one  or  more  of  the  arterial  tunics  which  have  become 
so  thickened,  blended,  and  changed  by  interstitial  growth  that  it  is  usually 
impossible  to  determine  their  exact  identity.  The  inner  and  middle  coats 
can  sometimes  be  recognized  by  the  patches  of  atheromatous  degeneration 
visible  in  their  structure.  In  large  aneurisms  the  two  inner  coats  have 
usually  disappeared  ;  indeed,  the  outer  one  may  be  absent  in  places  and 
its  place  be  supplied  by  the  external  investment  above  mentioned  and  the 
laminated  fibrine  contained  in  the  sac.  The  true  sac  is  of  varying  thick- 
ness in  different  regions  of  the  tumor. 

It  is  evident  that  in  all  aneurisms,  except  in  the  very  smallest,  there 
must  be  a  natural  growth  of  the  sac  wall  after  the  pouch  has  first  been 
formed,  for  the  area  of  tissue  that  constituted  the  arterial  wall  at  the  site 
of  disease  could  not  possibly  be  stretched  so  as  to  form  a  sac  of  such 
dimensions.  The  irregular  thickening  and  thinning  of  the  sac  depend 
upon  the  force  of  the  blood  current  in  the  aneurism.  Where  the  blood 
impinges  with  the  greatest  force,  there  will  the  sac  be  thinnest.  Inside 
the  true  sac  there  will  nearly  always  be  found  numerous  concentric  layers 
of  more  or  less  completely  decolorized  fibrine.  The  layers  of  fibrine 
nearest  the  sac  wall  are  tougher  and  more  yellow  than  those  nearer  the 
centre  of  the  aneurism,  which  are  softer  and  somewhat  reddish.  This 
laminated  fibrine  is  found  especially  in  those  irregular  pockets  or  pouches 


ANEURISM.  267 

of  the  sac  which  are  away  from  the  rapid  current  circulating  in  the 
aneurism.  This  deposition  of  fibi'ine  is  encouraged  by  any  agency, 
whether  within  the  aneurism  or  entirely  foreign  to  it,  that  diminishes  the 
force  of  the  current  within  the  tumor.  When  fibrine  has  once  begun  to 
form  upon  the  inner  wall  of  the  sac  it  has  a  tendency  to  increase  by 
further  deposition  of  the  blood.  Thus,  layer  after  layer  is  formed.  The 
outer  layers,  being  the  oldest,  naturally  become  more  decolorized  and 
tougher.  The  laminated  fibrine  is  a  beneficial  provision  of  nature  for, 
by  reason  of  its  tough,  fibrous  nature,  it  strengthens  the  sac  wall  and  acts 
as  a  pad  to  lessen  the  force  of  the  pulsating  blood  current,  which  is  tend- 
ing to  distend  and  rupture  the  sac.  Moreover,  it  lessens  the  capacity  of 
the  sac,  and  by  its  continual  deposition  tends  to  fill  up  and  obliterate  the 
cavity  of  the  aneurism.  Fusiform  aneurisms  usually  contain  little  or  no 
laminated  fibrine.  At  the  centre  of  the  aneurism,  within  the  concentric 
layers  of  fibrine,  there  will  be  found  a  mass  of  soft,  black  or  reddish- 
black  clot,  or  a  mixture  of  such  clot  and  fluid  blood.  This  soft  clot  may 
be  an  ante-mortem  or  a  post-mortem  formation. 

The  secondary  changes  produced  by  an  aneurismal  tumor  are  numerous 
and  are  due  especially  to  the  pressure  exerted  by  its  growth.  Thus, 
oedema,  varicose  veins,  and  venous  occlusion  may  occur  from  pressure  on 
the  veins ;  and  neuralgia,  paralysis,  anaesthesia,  obscure  pains,  and 
"  tired  "  sensations  may  result  from  nervous  compression.  Aphonia  may 
follow  if  the  function  of  the  recurrent  laryngeal  nerve  is  interrupted. 
Organs  are  displaced,  bones  and  cartilages  eroded  and  perforated,  synovial 
sacs  opened,  gangrene  of  distal  parts  determined,  and  many  other  de- 
structive processes  inaugurated  before  death  or  cure  occurs.  Gangrene 
may  be  due  to  pressure  causing  interference  with  circulation  to  the  parts 
below,  or  to  a  portion  of  laminated  fibrine  or  soft  clot  becoming  detached 
and  being  washed  into  one  of  the  distal  branches  and  plugging  it. 

Symptoms. — The  symptoms  of  aneurism  are  usually  of  gradual  develop- 
ment, but  occasionally  it  happens  that  the  patient  experiences  a  sensation 
of  something  giving  way,  which  is  accompanied  by  a  sudden,  sharp  pain, 
and  is  followed  by  the  appearance  of  a  tumor.  An  aneurismal  tumor  is 
usually  rounded  or  oval  in  outline,  and  is  covered  by  healthy  skin,  unless 
suppuration  or  ulceration  is  taking  place.  These  events  occur  only  in 
the  last  stages  of  the  disease. 

An  aneurism  gives  rise,  as  does  any  other  tumor  of  similar  size  and 
location,  to  certain  pressure  effects.  These  symptoms  are  in  no  way  charac- 
teristic, and  do  not  aid  in  establishing  a  differential  diagnosis.  In  addi- 
tion there  are  symptoms  depending  upon  the  relation  of  the  aneurismal 
tumor  to  the  circulation.  These  are  peculiar,  and,  when  found  in  combi- 
nation, are  pathognomonic  of  aneurism. 

The  pressure  of  an  aneurism  may  give  rise  to  a  pain,  numbness,  muscu- 
lar weakness,  or  paralysis,  venous  congestion,  oedema  and  varicosities, 
gangrene,  obstruction  to  breathing  and  swallowing,  and  many  other  symp- 
toms due  to  interference  with  the  function  of  special  organs.  Hoarseness, 
spasmodic  dyspnoea,  cough  or  uncontrollable  eructation  may  be  produced 
by  pressure  upon  the  laryngeal  or  other  branches  of  the  pneumogastric 
nerve  ;  facial  distortion,  deafness,  ptosis,  or  strabismus  from  similar  involve- 
ment of  cranial  nerves ;  boring  pain  or  even  synovitis  from  erosion  and 
perforation  of  bones  and  cartilages,  and  nutritive  changes  from  involve- 
ment of  lymphatic  vessels  or  thoracic  duct.  The  pressure  effects  of  an 
aneurism  are  apparently  more  rapidly  developed  than  those  of  an  ordi- 


268  DISEASES    OF    THE    ARTERIES. 

nary  tumor  of  similar  size.  This  is  probably  due  to  the  pulsating  charac- 
ter of  the  former. 

The  symptoms  due  to  the  circulatory  relations  of  the  aneurism  may  be 
called  intrinsic  symptoms,  and  are  five  in  number,  namely,  location, 
change  in  tension,  pulsation,  thrill,  murmur.  An  aneurism  is  necessarily 
located  in  the  course  of  an  arterial  trunk,  and  cannot  hn  displaced  from 
its  connection  with  the  artery.  If  occluding  digital  pressure  is  made  upon 
the  vessel  below  the  aneurism,  the  tumor  becomes  more  tense  and  less 
compressible  ;  and  if  the  sac  contains  but  little  laminated  fibrine  and  has 
thin  walls,  the  tumor  may  even  become  larger  than  usual  by  the  stretch- 
ing influence  of  the  unusual  amount  of  blood  dammed  up  in  it.  If  the 
entrance  of  blood  into  the  sac  is  prevented  by  pressure  upon  the  artery 
above  the  aneurism,  the  tension  is  diminished  and  the  tumor  becomes  com- 
paratively flaccid  and  compressible.  The  elastic  bandage  when  tightly 
applied  to  the  limb,  as  in  ])loodless  operating,  often  causes  a  marked  dimi- 
nution in  the  size  of  the  tumor.  It  may  do  harm,  however,  by  displacing 
portions  of  fibrine  and  causing  embolism. 

The  compressibility  or  non-compressibility  of  individual  aneurismal 
tumors  is  chiefly  <letermined  by  the  absence  or  presence  in  them  of  a  large 
amount  of  laminated  fibrine.  The  variation  in  compressibility  or  ten- 
sion, observed  when  the  exit  or  entrance  of  blood  is  checked,  is  due  to  the 
degree  of  distention  of  the  sac  by  its  circulating  blood  contents.  When 
the  sac  contains  much  fibrine,  or  has  a  thick  wall,  this  symptom  is  not 
well  marked. 

The  pulsation  of  an  aneurism  is  a  peculiar  expansive  beat,  wdiich  not 
only  lifts  the  fingers  or  hand  laid  upon  the  top  of  the  tumor,  but  drives 
apart  the  fingers  or  hands  when  the  tumor  is  grasped  laterally.  This 
lateral  pulsation  is  due  to  the  fluid  contents  of  the  aneurism  transmitting 
the  shock  of  the  heart-beat  e(|ually  in  all  directions.  When  the  sac  is 
largely  filled  with  fibrine,  and,  therefore,  has  little  blood  contents,  this 
lateral  pulsation  is  less  marked,  and  only  a  dead  thud  is  perceived. 
Another  peculiarity  of  aneurismal  pulsation  is  the  wave-like  movement. 

The  pulsation  does  not  seem  to  affect  all  parts  of  the  tumor  simultane- 
ously, but  swells  up  somewhat  gradually  as  if  propagated  from  one  point, 
and  then  in  a  similar  way  subsides.  Pressure  upon  the  artery  above  the 
tumor  arrests  pulsation  ;  pressure  below  it  and  elevation  of  the  limb  have 
a  tendency  to  make  it  more  marked.  Aneurisms  with  large  orifices,  and 
which  contain  little  fibrine,  present  the  most  characteristic  pulsation.  In 
partially  solidified  aneurisms  the  pulsation  may  be  absent  or  obscure,  or 
may  resemble  the  simple  rise  and  fall  of  a  solid  tumor  lying  upon  an 
artery.  Pulsation  may  also  be  absent  because  of  rupture  of  the  anuerism, 
because  of  inflammatory  infiltration  between  the  sac  and  the  surface, 
because  loose  clots  have  plugged  the  orifice  of  communication,  or  because 
the  disease  has  just  been  spontaneously  cured,  and  the  tumor  has  not  yet 
entirely  disappeared.  When  the  artery  is  compressed  above  the  seat  of 
disease,  so  that  no  blood  enters  the  sac,  the  tumor,  as  previously  stated, 
becomes  pulseless  and  flaccid.  If  the  tumor  is  now  grasped  laterally, 
and  the  pressure  upon  the  vessels  suddenly  removed,  the  expanding 
pulsation  by  which  the  sac  is  instantly  refilled,  is  readily  felt  and  even 
seen.  When  the  sac  has  a  large  mouth,  one  pulsation  distends  it  fully ; 
if  the  orifice  is  small,  the  sac  fills  more  slowly,  but  the  first  pulsations 
are  strong  beats. 

The  arterial  pulse  below  the  aneurism  is  much  less  marked  than  on  the 
opposite  side  of  the  body.     This  may  be  due  to  pressure  of  the  tumor  on 


ANEURISM.  269 

the  artery,  to  arteritis  causing  occlusion,  or  to  the  rigidity  of  calcification. 
It  is  possible  that  it  may  also  be  caused  by  the  large  amount  of  blood  in 
the  sac  distributing  the  pulsation  and  lessening  that  in  the  current  below. 
This  variation  in  the  two  radial  arteries  is  of  aid  at  times  in  diagnosticat- 
ing aneurism  of  the  thoracic  aorta.  Just  after  the  heaving  pulsation  of 
an  aneurism,  the  hand  of  the  examiner  can  often  perceive  a  peculiar 
tremulous  or  vibratory  movement  called  the  thrill.  The  thrill  is  due  to 
the  rebound  of  the  blood  column,  and  is  said  to  be  more  distinct  when  the 
artery  lies  between  the  sac  and  the  surface  upon  which  the  hand  is  placed. 
The  last  of  the  five  intrinsic  symptoms  of  aneurism  is  the  murmur  or 
bruit.  This  is  an  intermittent  blowing,  rasping,  or  purring  sound  due  to 
the  blood  rushing  through  the  narrow  mouth  into  the  dilated  cavity  of 
the  sac.  It  is  heard  by  applying  the  ear  either  with  or  without  a  stetho- 
scope to  the  surface  of  the  tumor.  The  tone  varies  greatly,  depending 
on  the  size,  shape,  and  location  of  the  orifice,  its  relation  to  the  sac,  and 
perhaps  upon  the  character  of  the  surrounding  tissues.  It  is  most  dis- 
tinct in  fusiform  aneurisms  and  sacciform  aneurisms  with  large  mouths. 
It  is  synchronous  with  the  aneurismal  pulsation,  and  is  stopped  by  pres- 
sure on  the  artery  above  the  sac,  but  returns  as  soon  as  the  pressure  is 
removed  and  the  blood  allowed  to  flow  into  the  sac.  If  the  tension  of 
the  sac  is  lessened  by  elevating  the  limb  or  by  compression  of  the  artery 
above  the  tumor,  the  murmur  may  sometimes  be  heard  in  cases  in  which 
it  was  previously  absent.  Increasing  the  tension  by  pressing  upon  the 
artery  below  would,  on  the  other  hand,  have  a  tendency  to  diminish  the 
murmur.  If  the  orifice  is  very  small  or  the  sac  nearly  filled  with  fibrine 
there  may  be  no  murmur  generated.  The  aneurismal  murmur  is  not  in- 
frequently absent,  and,  indeed,  may  be  present  at  one  time  and  afterward 
disappear.  A  double  murmur  indicates,  according  to  Erichsen,  a  sacci- 
form aneurism. 

These  intrinsic  symptoms  may  not  all  be  present  in  a  given  aneurism, 
but  the  association  of  two  or  more  of  them  usually  renders  the  diagnosis 
quite  clear. 

When  an  aneurism  ruptures,  permitting  the  blood  and  clots  to  become 
diffused,  the  tumor  loses  its  definite  outline  and  becomes  rapidly  larger. 
Pulsation,  thrill,  and  murmur  become  obscure  or  absent ;  pain  increases, 
and  coldness,  lividity,  and  oedema  of  the  extremity  are  apt  to  occur.  The 
subcutaneous  hemorrhage  may  cause  syncope.  Coagulation  of  the  blood 
and  inflammatory  condensation  of  the  cellular  tissue  may  in  very  occa- 
sional instances  limit  diflTusion  after  the  rupture  and  lead  to  spontaneous 
cure  of  the  aneurism.  Usually,  however,  the  swelling  increases,  and  the 
case  terminates  in  gangrene  or  suppuration,  accompanied  most  likely  with 
hemorrhage. 

Diagnosis. — The  differential  diagnosis  of  aneurism  from  other  tumors 
should  always  receive  careful  and  systematic  attention.  'No  swelling  near 
an  artery  should  ever  be  laid  open  until  the  possibility  of  aneurism  has 
been  eliminated  by  accurate  examination. 

The  pain  caused  by  internal  aneurism  may,  when  the  tumor  is  not 
easily  discoverable,  be  mistaken  for  rheumatism  or  neuralgia.  Such  an 
error  is  hardly  probable  in  the  external  aneurisms  that  come  under  the 
observation  of  surgeons.  There  are  two  circumstances  that  at  times 
render  the  differential  diagnosis  of  aneurism  troublesome.  First,  there 
are  pulsating  tumors  that  are  not  aneurisms ;  and  secondly,  there  are 
aneurisms  that  do  not  pulsate. 

Any  solid  or  cystic  tumor  or  abscess  situated  over  a  large  artery  may 


270  DISEASES    OF    THE    ARTERIES. 

sliow  transmitted  pulsation.  The  pulsation  in  such  cases  is  not  so  expan- 
sive as  in  aneurism, -but  is  rather  a  simple  rise  and  fall  which  may  be 
diminished  or  stopped  when  the  tumor  is  pushed  or  lifted  away  from  the 
artery.  Flexinir  the  limb  so  as  to  relax  the  deep  fascia  will  |)robably 
lessen  the  pulsation,  which,  moreover,  is  sometimes  felt  only  in  the  line 
of  the  artery  and  not  over  the  entire  tumor.  There  is  no  murmur,  or  if 
any,  it  is  only  a  dull  beatintr  such  as  is  heard  when  an  artery  is  com- 
pressed with  a  stethoscope.  The  tension  and  size  of  such  tumors  are  not 
affected  by  occluding  pressure  upon  the  artery  above  or  below  the  swell- 
ing. The  suddenness  with  which  aneurisms  regain  their  usual  size  when 
arterial  pressure  on  the  cardiac  side  of  the  tumor  is  removed  is  very 
characteristic,  and  is  not  present  in  tumors  with  a  mere  transmitted  pul- 
sation. 

Cysts  or  ab.scesses  communicating  with  a  joint,  or  with  the  abdominal 
or  any  other  cavity,  may  be  partially  emptied  by  pressure  ;  but  they  refill 
afterward  without  reference  to  the  arterial  circulation.  An  abscess  sit- 
uated above  or  surrounding  an  aneurism  will  appear  as  a  tumor  having 
pulsation,  and  some  of  the  other  symptoms  of  aneurism.  .Such  cases  are 
fortunately  rare.  The  aspirator  would  be  available  for  establishing  the 
diagnosis.  If  the  suppuration  is  due  to  rupture  of  the  aneurism  the 
opening  between  the  sac  and  the  pus  collection  will  permit  hemorrhage 
to  follow  the  opening  of  the  abscess.  Pulsation  is  usually  feeble  or  absent 
in  such  conditions,  and  unless  the  previous  history  is  ol)tained  the  surgeon 
may  be  misled  into  laying  open  the  tumor.  The  fatal  bleeding  may  not 
occur  until  some  hours  after  the  incision,  because  the  laminated  fibrine 
may  for  a  time  act  as  a  barrier.  A  murmur  should  be  carefully  sought 
in  such  cases,  since  it  is  less  likely  to  be  absent  than  other  aneurismal 
phenomena 

Some  vascular  tumors  or  angeioraas  resemble  aneurisms  very  much. 
They  are  apt,  however,  to  have  a  more  spongy  feel,  and  are  not  so  dis- 
tinctly circumscribed  as  aneurisms.  If  the  blood  is  pressed  out  of  such  a 
tumor  it  returns  somewhat  tardily  and  irregularly,  causing  the  tumor  to 
dilate  slowly  and  unevenly,  and  not  with  the  sudden  l)ound  that  is  seen 
in  aneurisms.  Pressure  upon  the  artery  below  causes  no  marked  increase 
in  size  of  tumor.  The  pulsation  is  not  as  forcible  or  as  distinct  as  an 
aneurism,  and  it  lacks  the  expansive  and  wave-like  character  of  the  pul- 
sation found  in  the  latter  disease.  The  murmur  is  more  confused  and  less 
well  defined.  The  introduction  of  a  hollow  needle  will  probably  give 
exit  to  blood,  but  the  blood  will  scarcely  spurt  as  in  the  event  of  puncture 
of  an  aneurismal  sac,  nor  will  the  needle  be  likely  to  give  to  the  surgeon's 
hand  the  sensation  of  having  its  end  in  a  cavity. 

Malignant  tumors,  especially  sarcomas  of  the  bones,  may,  when  very 
vascular,  assume  pulsation.  If  in  localities  where  aneurism  is  common 
the  diagnosis  becomes  at  times  almost  impossible.  The  history  of  such 
growths  generally  shows  that  pulsation  was  not  present  when  the  tumor 
first  appeared,  and  that  the  growth  has  recently  become  of  softer  consist- 
ence than  formerly.  Careful  examination  shows  that  the  pulsation  is  not 
very  distinct,  that  the  murmur  is  soft  and  subdued,  and  that  little  varia- 
tion in  size  is  produced  by  pressure  on  the  artery  between  the  tumor  and 
the  heart.  The  pulsation  and  murmur  after  having  once  appeared  do 
not,  as  in  aneurism,  become  more  conspicuous  as  the  bulk  of  the  growth 
is  augmented  ;  often  these  phenomena  are  perceptible  only  over  certain 
parts  of  the  tumor.  Involvement  of  the  adjacent  lymphatic  glands  sug- 
gests malignant  disease,  which,  moreover,  is  apt  to  be  more  or  less  irreg- 


ANEURISM.  271 

ular  in  outline.  In  very  obscure  cases  an  attempt  might  be  made  to 
remove  a  small  portion  of  the  interior  of  the  tumor  for  microscopic  ex- 
amination by  inserting  an  instrument  such  as  is  used  for  cutting  out 
pieces  of  muscle  in  cases  of  suspected  trichinosis. 

Aneurisms  that  are  devoid  of  pulsation  may  be  mistaken  for  deep 
abscesses  and  for  granular,  fibroid,  and  other  tumors.  The  pulsation 
ceases  in  an  aneurism  when  spontaneous  consolidation  has  occurred,  or 
when  rupture  or  diffusion  of  the  blood  contents  has  taken  place. 

An  aneurism,  when  spontaneously  cured  by  consolidation,  continues  for 
a  long  time  as  a  hard  mass,  which  finally  shrinks  and  disappears.  Such 
a  mass  cannot  easily  be  distinguished  from  other  hard  tumors  except  by 
the  history.  A  tumor  located  near  an  artery,  especially  if  it  shows  a 
tendency  to  decrease,  should,  therefore,  be  well  scrutinized  before  any 
operative  treatment  for  extirpation  is  attempted.  When  a  small  rupture 
of  the  sac  occurs,  the  effused  blood  conceals  pulsation,  changes  the  ordi- 
nary globular  shape  of  the  aneurism,  and,  by  gravitating  away  from  the 
seat  of  disease,  may  make  the  tumor  appear  to  have  a  site  distant  from 
the  line  of  the  artery.  Moreover,  the  superficial  veins  may  become 
unusually  marked,  because  the  cii'culation  in  the  deep  veins  is  interfered 
with  by  reason  of  the  pressure.  This  circumstance  gives  the  tumor  the 
appearance  of  malignant  disease.  Aneurisms,  which  are  the  seat  of  small 
ruptures,  are,  therefore,  at  times  diagnosticated  from  solid  tumors  with 
difficulty.  The  diagnosis  is  easily  made  when  the  rupture  is  large,  for 
the  interruption  of  circulation  in  tlie  limb  below,  the  swelling,  pain, 
ecchymosis,  and  rapidly  occurring  suppuration  and  gangrene  are  quite 
distinctive.  If  suppuration  occurs  around  an  aneurism,  from  inflamma- 
tion due  to  pressure  or  to  rupture,  pulsation  maybe  absent.  The  careless 
surgeon  may  plunge  a  bistoury  into  such  a  swelling  and  cause  fatal 
bleeding.     This  has  been  spoken  of  above. 

Finally,  abnormal  pulsation  of  an  artery  is  at  times  noticeable  in  con- 
ditions of  debility  and  in  nervous  subjects,  and  may  be  mistaken  for 
aneurism.  The  absence  of  lateral  or  expansive  pulsation  and  of  a  tumor 
serves  to  dispel  the  illusion. 

Course  and  Ter:mixation. — Untreated  aneurism  generally  continues 
to  increase  in  size  until  death  occurs  from  :  (.1)  Pressure  interfering  with 
important  organs,  such  as  the  trachea,  pneumogastric  nerve,  or  heart ;  (^2) 
syncope,  from  weakness  of  cerebral  circulation  beyond  the  large  sac ; 
(8)  embolism  of  the  cerebral  arteries  from  fragments  washed  from  the 
laminated  clots;  (4)  rupture  and  hemorrhage;  (5j  gangrene,  from  pres- 
sure on  the  vessels  of  the  limb.  When  an  aneurism  bursts  upon  a  serous 
surface  the  hemorrhage  is  usually  rapid,  and  occurs  through  a  slit  or 
star-like  tear  ;  but  when  the  rupture  is  upon  a  mucous  surface,  the  bleeding 
is  apt  at  first  to  be  intermittent  and  so  slight  as  scarcely  to  attract  atten- 
tion as  it  oozes  through  a  small  fissure.  Subsequently,  on  the  occasion  of 
some  increase  in  blood  pressure  from  emotion  or  exertion,  a  small  slough 
gives  Avay  and  a  sudden  gushing  hemorrhage  supervenes  through  a  small 
circular  apeture.  Kupture  upon  the  cutaneous  surface  takes  place,  as  a 
rule,  by  the  processes  of  ulceration  or  suppuration  and  pointing  as  in 
abscesses.  Rupture  of  the  sac  may,  of  course,  occur  without  external 
communication.  In  such  cases  the  blood  is  effused  among  the  muscles 
and  fascias,  and  commonly  leads  very  promptly  to  suppurative  or 
gangrenous  inflammation. 

Occasionally,  but  rarely,  an  aneurism  is  cured  spontaneously.  Any 
agency  that  lessens  the  blood-current  and  thereby  encourages  the  deposi- 


272  DISEASES    OF    THE    ARTERIES. 

tion  of  laminated  fibrine  and  the  coagulation  of  blood  in  the  sac,  may  be 
a  factor  in  this  fortunate  issue.  Absolute  quiet  of  mind  and  body  and 
maladies  that  depress  the  general  circulation  or  draw  the  mass  of  the  blood 
to  a  region  distant  from  the  seat  of  aneurism,  have  this  tendency.  The 
aneurism  itself  or  some  other  tumor  may  compress  the  artery  above  the 
seat  of  disease,  and  thus  diminish  the  current  through  the  sac.  Sponta- 
neous cure  may  also  occur  from  occlusion  of  the  vessel  above  or  below 
the  disease  by  an  embolic  plug  swept  from  vegetations  in  the  heart,  or 
from  the  fibrine  in  the  aneurismal  sac;  from  inflammation  of  the  sac 
wall,  causing  within  the  aneurism  the  formation  of  soft  clot;  from  sup- 
puration ;  from  rupture  ;  and  from  gangrene.  Any  of  these  processes 
may  at  times  fortunately  cause  sealing  of  the  vessel  and  obliteration  or 
destruction  of  the  sac ;  but  they  are  dangerous  complications  not  often 
attended  by  such  a  gratifying  result. 

Trkatment. — The  medical  or  constitutional  treatment  of  aneurism  is 
important,  even  in  those  instances  that  require  additional  surgical  inter- 
ference. Absolute  rest  of  body  and  mind  must  be  enforced  by  keeping 
the  patient  in  bed  in  the  recumbent  position,  and  free  from  the  excitement 
of  talking.  He  should  be  cautioned  to  avoid  rapid  or  frequent  move- 
ments of  the  limbs,  and  not  to  rise  in  bed  unless  aided  by  attendants. 
He  should  not  get  out  of  bed  on  any  pretence.  The  food  should  be  limited 
in  quantity,  and  free  from  stimulating  or  indigestible  ingredients.  Very 
little  water  or  fluid  diet  should  be  given.  The  design  of  these  precau- 
tions is  to  diminish  the  bulk,  and  retard  the  circulatory  force  of  the 
blood  in  order  that  deposition  of  laminated  fibrine  in  the  sac  may  be 
encouraged.  These  objects  may  be  further  obtained  if  the  patient  is 
robust  and  plethoric  by  a  moderate  bleeding  from  the  arm,  and  the 
administration  of  aconite  and  veratrum  viride  in  comparatively  small 
doses.  Bromide  of  potassium,  hydrate  of  chloral,  and  the  other  narco- 
tics may  be  employed  here,  and  also  in  a  debilitated  subject  to  induce 
circulatory  repose.  Iodide  of  potassium  has  been  strongly  recommended 
in  the  treatment  of  aneurism.  It  should  be  given  in  doses  of  20  to  30 
grains  two  or  three  times  daily. 

The  medical  treatment  just  delineated  is  the  only  treatment  applicable 
to  the  majority  of  internal  aneurisms,  as  aneurisms  within  the  cavities  of 
the  trunk  are  called.  It  should  also  be  employed  as  an  adjuvant  to 
surgical  measures  in  cases  of  external  aneurism.  Though  cure  of  any 
form  of  aneurism  by  medical  means  is  rather  unusual,  amelioration  of 
symptoms  and  retardation  of  progressive  enlargement  are  their  common 
sequences.  Fusiform  aneurisms  cannot,  but  sacciform  aneurisms  may,  be 
cured  by  such  measures. 

Many  surgical  expedients  have  been  devised  for  dealing  with  aneurism. 
There  are  but  three  that  possess  sufficient  value  to  be  discussed  in  this 
treatise. 

These  are : 

1.  Excision  of  the  tumor,  which  is  applicable  to  very  small  aneurisms 
only,  such  as  occur  in  the  fingers. 

2.  Compression  of  the  artery  above  the  tumor  by  instruments,  the 
fingers,  flexion  of  the  joint,  or  the  Esmarch  apparatus. 

'■-).  Arterial  ligation. 

Galvano-puncture,  acupuncture,  the  introduction  into  the  sac  of  foreign 
bodies,  such  as  horsehair  or  wire,  injections  of  coagulating  liquids,  such 
as  the  iron  compounds,  manipulation  which  aims  to  detach  fragments  of 
fibrine  and   plug  the  distal  orifice  of  the  sac,  and  the  other  proposed 


ANEURISM.  273 

methods  are  either  far  inferior  to,  or  much  more  dangerous  than  the  pro- 
cedures mentioned  above.  Still  it  may  be  justifiable  to  resort  to  one  of 
these  methods  when  those  recommended  are  impracticable. 

Amputation  may  be  demanded  as  a  last  resort  in  order  to  save  life  in 
aneurisms  of  the  extremities  that  threaten  immediate  death  from  hemor- 
rhage or  gangrene. 

Excision  of  the  aneurismal  sac  is  applicable  only  to  small  aneurisms 
such  as  occur  in  the  hands  and  feet.  In  these  situations  excision  is  some- 
times to  be  employed  because  the  intimate  anastomosis  of  vessels  renders 
solidification  of  the  aneurism  by  either  compression  or  ligation  of  the 
main  vessels  of  the  limb  diflScult.  The  method  is  simple.  After  the 
application  of  the  Esmarch  apparatus  the  tumor  is  dissected  out  as  any 
other  growth  would  be  and  the  vessel  tied  above  and  below  the  seat  of 
dilatation.  The  wound  is  then  brought  together  with  sutures.  A  some- 
what similar  method,  which  may  be  called  the  incision  method,  is  at  times 
justifiable  in  large  aneurisms,  though  it  is  seldom  employed  except  in 
cases  of  rupture  or  accidental  puncture  of  an  aneurism.  After  the  circu- 
lation has  been  controlled  by  compression  or  the  Esmarch  apparatus,  the 
sac  is  incised,  so  that  the  clots  can  be  turned  out  and  the  orifice  in  the 
artery  discovered.  Into  this  aperture  a  probe  is  passed  to  enable  the 
operator  to  detect  the  position  of  the  vessel,  which  is  then  ligated  above 
and  below  the  opening.  The  wound  is  afterward  brought  together  by 
sutures  or  packed  with  some  antiseptic  dressing  and  allowed  to  granulate. 

Compression,  as  a  method  of  treating  aneurism,  may  be  applied  directly 
to  the  tumor,  or  to  the  artery,  either  above  or  near  the  seat  of  disease. 
Pressure  applied  directly  to  the  tumor  or  to  the  artery  on  the  distal  side 
of  the  aneurism  is  seldom  effective  and  needs  no  further  description. 
Proximal  arterial  compression  is  the  form  adopted  in  all  cases ;  for  even 
in  those  in  which  flexion  is  employed  it  is  the  compression  exerted  on  the 
artery  above  the  sac  that  is  the  chief  element  of  value.  Compression  of 
the  artery  above  the  aneurism  acts  by  diminishing  or  completely  arresting 
the  flow  of  blood  through  the  sac.  This,  in  the  one  case,  encourages 
gradual  deposit  of  laminated  fibrine  which  finally  fills  the  pouch  and 
leads  to  solidification ;  and  in  the  other,  causes  the  sac  to  become  filled 
with  soft  clot,  after  which,  under  the  influence  of  absorptive  and  con- 
tractile influences,  the  aneurism  shrinks  and  becomes  obliterated. 

It  is  probable  that  here,  as  in  ligation,  the  more  certain  and  safe  treat- 
ment is  that  in  which  the  pressure  is  so  regulated  that  a  small  amount  of 
blood  is  allowed  to  enter  the  aneurismal  pouch  during  the  application  of 
the  compressing  force.  Thus,  a  slow,  laminated  deposit  of  fibrine  occurs 
and  the  sac  becomes  hard  and  solid.  When  sufficient  pressure  is  made 
upon  the  artery  to  close  its  calibre  entirely,  the  anastomosing  arteries,  if 
the  jDressure  is  continuous,  will  soon  carry  a  small  blood-stream  through 
the  tumor,  provided  a  branch  leaves  the  main  trunk  between  the  seat  of 
compression  and  the  sac.  The  conditions  are  thus  identical  with  those 
obtaining  after  Hunter's  method  of  ligation ;  providing  the  occluding 
pressure  is  maintained  without  interruption  for  a  sufficient  number  of 
hours  and  is  not  changed  to  a  point  below  the  origin  of  the  branch 
through  which  the  small  reversed  current  is  to  enter  the  main  trunk. 

When  the  compression  is  only  sufficient  partially  to  close  the  arterial 
calibre,  a  small  amount  of  blood  necessarily  enters  the  pouch  by  the 
ordinary  route,  and  the  therapeutic  conditions  are  similar  to  those  just 
described.  When  the  complete  compression  is  made  so  near  the  sac  that 
no  intervening  branch  exists  all  access  of  blood  to  the  sac  is  stopped  and 

18 


274 


DISEASES    OF    THE    ARTERIES. 


it  becomes  filled  with  soft  clot.  Cure  must  then  result  as  in  Anel's  method 
of  licjating,  and  with  the  same  liability  to  ftiilure  from  inflammatory  reac- 
tion due  to  the  pressure  of  the  soft  coagulum. 


Fig.  105. 


Diagram  showing  small  amount  of  l>iOo<l  entering  sac  because  pad  of  compressor  does 
uot  entirely  occlude  the  calibre  of  the  artery. 

It  takes  longer  to  fill  the  sac  with  deposits  of  laminated  fibrine  than 
with  soft,  homogeneous  coagulum  ;  but  reasoning  from  what  is  seen  after 
ligation  I  am  inclined  to  recommend  it  as  the  surer  and  safer  method. 
Therefore,  that  complete  compression,  as  a  rule,  should  not  be  employed 
unless  the  pressure  can  be  applied  far  enough  above  the  aneurism  to  in- 
sure the  existence  of  an  intervening  branch  which  will  carry  a  gentle 
current  of  blood  through  the  sac,  partial  compression  may  be  employed 
even  near  the  aneurism  because  it  allows  a  portion  of  the  current  to  pass 
through  the  vessel  at  the  seat  of  pressure  and  thus  enter  the  sac. 

By  complete  compression  is  not  meant  such  a  degree  of  force  as  will 
cause  inflammation  of  the  tunics  and  permanent  occlusion  of  the  artery  ; 
merely  such  pressure  as  will  bring  the  opposite  walls  of  the  vessel  in  con- 
tact and  prevent  the  passage  of  the  blood  current  during  the  continuance 
of  the  pressure.  This  sort  of  compression  should  be  continued  for  from 
four  to  ten  hours,  and  usually  requires  anaesthesia  during  the  whole  period, 
for  the  prevention  of  discomfort  and  actual  pain.  When  the  aneurismal 
tumor  appears  to  have  become  consolidated,  which  may  occur  in  a  short 
time,  the  pressure  may  be  somewhat  relaxed  ;  but  partial  compression  at 
least  should  be  maintained  for  several  hours  longer.  If  this  is  not  done, 
the  sudden  rush  of  blood  may  displace  the  fibrinous  deposits  in  the  sac  ; 
or,  if  the  coagulum  is  merely  soft,  may  cause  its  disintegration  and  thus 
destroy  the  prospects  of  cure. 

Partial  compression,  which  allows  some  blood  to  flow  through  the 
artery  at  the  point  of  pressure,  is  more  tolerable  to  the  patient  than  com- 
plete compression,  and,  therefore,  does  not  require  anaesthesia.  Narcotics 
may  be  demanded,  however,  to  relieve  distress  occasioned  by  the  restraint. 
This  method  of  treatment  must  be  continued  for  days,  and  perhaps  for 
two  or  three  weeks,  because  the  blood  current,  though  greatly  diminished 
in  volume,  is  sufiicient  to  prevent  rapid  solidification  in  the  sac. 

Either  form  of  compression  may  be  employed  continuously  or  inter- 
ruptedly. Continuous  compression  is  probably  better  than  interrupted 
compression,  whether  complete  or  partial,  because  cure  is  more  rapidly 
attained.  It  quite  frequently  happens,  however,  that  treatment  by  either 
complete  or  partial  compression  requires  so  many  hours  or  becomes  so 
irksome  to  the  patient,  that  it  is  necessary  to  suspend  its  employment  from 
time   to  time.     The  intervals  of  non-treatment  should   be  generally  at 


ANEURISM.  275 

night,  so  that  the  patient  may  have  every  opportunity  for  obtaining  rest 
and  sleep.  In  the  case  of  complete  compression  an  intermission  of  several 
days  is  at  times  advisable.  During  the  intermissions  the  patient  should 
be  kept  perfectly  quiet  in  bed.  The  sac  is  finally  filled,  if  cure  be  effected, 
by  successive  layers  of  fibrine  deposited  during  the  periods  of  pressure. 

The  best  method  of  compression  probably  is  continuous  complete  com- 
pression applied  far  enough  above  the  aneurism  to  insure  the  existence  of 
an  intervening  branch  to  carry  a  little  blood  into  the  sac.  If  this  form 
of  treatment  is  not  adaptable  resort  may  be  had  to  continuous  partial 
compression. 

After  an  aneurism  has  been  cured  by  compression  there  is  usually  no 
obliteration  of  the  artery  found  at  the  point  of  pressui-e.  In  the  sacciform 
variety  there  is  in  some  instances  no  obliteration  even  at  the  seat  of  the 
tumor,  but  the  circulation  goes  on  through  a  groove  or  channel  in  the 
solidified  aneurism.  Fusiform  aneurisms  are  not  very  amenable  to  treat- 
ment by  pressure. 

Before  compression  is  begun  the  patient  should  be  confined  to  bed  for 
three  or  four  days,  that  he  may  become  accustomed  to  the  restraint  and 
to  urinating  and  defecating  in  the  supine  posture. 

The  limb  should  be  shaved  and  washed,  and  the  skin  at  the  seat  of  pro- 
posed pressure  sprinkled  with  chalk,  oxide  of  zinc,  soapstone,  or  other 
unirritating  powder.  The  bed  should  have  a  firm  mattress  upon  it.  The 
intelligent  cooperation  of  the  patient  should  be  obtained,  for  much  depends 
upon  the  contiuuous  perfect  adjustment  of  the  compressing  force  whether 
it  be  digital  or  instrumental. 

Bromide  of  potassium,  chloral  and  morphia  are  often  valuable  agents 
for  keeping  the  patient  comfortable.  When  about  to  apply  the  compress- 
ing force  the  surgeon  should,  by  momentary  pressure  on  the  distal  portion 
of  the  artery,  cause  the  sac  to  become  well  distended  with  blood.  The 
finger  or  pad  is  then  adjusted  to  the  artery  above  the  aneurism  before  the 
distal  pressure  is  relaxed.  Gentle  compression  of  the  tumor  by  an  ordi- 
nary bandage  applied  up  the  limb  during  the  time  of  treatment  possibly 
conduces  to  hastening  contraction  of  the  sac.  Inflammation  of  the  skin 
or  cellular  tissue  at  the  point  of  compression  calls  for  temporary  cessation 
of  treatment. 

The  best  compressing  force  is  that  exerted  by  the  human  finger.  This 
is  called  digital  compression,  as  opposed  to  instrumental  compression, 
which  is  obtained  by  tourniquets,  suspended  weights,  or  similar  appara- 
tus. Digital  compression  necessitates  relays  of  physicians  or  trained 
assistants,  since  one  person  cannot  exert  effective  digital  pressure  continu- 
ously for  more  than  ten  or  fifteen  minutes.  Two  persons  should  be  with 
the  patient  constantly.  The  first  makes  pressure  on  the  artery  with  his 
thumbs  placed  one  upon  the  other,  while  the  second  keeps  his  hand  on  the 
surface  of  the  aneurism  to  see  that  absolute  cessation  of  pulsation  is  main- 
tained. When  the  first  becomes  tired  of  pressing,  the  second  places  his 
thumbs  upon  the  vessel  just  above  or  just  below  the  point  compressed  by 
his  companion  and  controls  the  circulation  before  the  latter  relaxes  his 
pressure.  He  that  was  the  compressor  now  watches  the  tumor  to  see  that 
pulsation  does  not  return  from  inefficient  arterial  occlusion.  Instead  of 
using  the  muscular  power  of  the  second  hand  to  reinforce  the  thumb  placed 
over  the  artery,  the  compressor  may  have  a  bag  of  shot  or  a  tourniquet 
so  adjusted  as  to  press  upon  the  back  of  his  thumb.  This  renders  the 
operation  less  wearisome.  Intelligent  assistants  are  required  for  carrying 
out  digital  compression,  since  the  pressure  must  be  made  in  that  direction 


276 


DISEASES    OF     THE     ARTERIES. 


Fig.  IOC. 


which  will  press  the  artery  against  the  bone;  and  must  not  be  made  upon 
the  vein  if  is  possible  to  avoid  it. 

The  femoral  artery  .should  be  controlled  by  pressure  below  the  groin 
directed  backward  against  the  head  of  the  femur.  The  brachial  artery 
at  its  upper  partis  compressed  by  pressure  outward  and  backward  against 
the  shaft  of  the  humerus.  The  amount  of  force  should  be  no  greater 
than  that  which  stops  pulsation  in  the  tumor.  It  is  for  these  reasons  that 
the  finger-tip  of  an  intelligent  person  is  far  better  than  any  pad  that  can 
be  devised  by  instrument-makers.  Complete  occlusion  can,  therefore, 
generally  be  maintained  without  aniesthe-sia.  Another,  though  indirect 
advantage  of  digital  compression,  is  the  constant  presence  of  the  assist- 
ants, which  serves  to  interest  and  encourage  the  patient. 

When  trained  assistants  are  not  obtainable, 
digital  has  to  be  substituted  by  instrumental 
pressure.  iSometimes  one  method  may  be 
used  as  an  adjuvant  to  the  other. 

Various  tourniquets  and  compressors  have 
been  devised  for  making  pressure  on  the  ar- 
tery. The  essential  point  is  that  the  venous 
circulation  shall  be  interfered  with  as  little 
as  possible ;  hence  a  .small  pad  c(mtrolled  by 
a  screw  or  spring  and  a  larger  pad  to  make 
counter-pressure  on  the  opposite  side  of  the 
limb  are  characteristics  of  nearly  all  these 
instruments.  Sometimes  there  are  a  series  of 
small  pads  so  that  pressure  can  be  applied 
alternately  to  different  parts  of  the  artery, 
and  thus  relieve  the  integument  from  inju- 
rious pi'essure.  The  same  object  can  be  ob- 
tained by  using  two  single  pad  tourniquets 
placed  a  few  inches  apart,  one  of  which  can 
l)e  relaxed  while  the  other  is  screwed  down 
upon  the  vessel. 

These  methods  are  objectionable  when  the 
varying  points  of  pressure  cause  different 
anastomosing  branches  to  carry  on  the  collat- 
eral circulation,  for  too  much  blood  may  reach 
the  sac  in  case  ligation  is  required  after  failure 
A  single  pad  is  probably  preferable,  supple- 
mented, if  necessary,  by  digital  compression  applied  near  the  same  spot. 
A  conical  weight  or  a  bag  of  shot  may  be  suspended  or  other  means 
arranged  .so  as  to  make  arterial  compression. 

When  the  aneurism  is  of  the  brachial  artery  at  the  elbow,  or  of  the 
popliteal  artery,  compression  l)y  flexion  may  be  employed  as  a  method  of 
treatment.  This  mode  consists  in  keeping  the  elbow  or  knee  firmly  flexed 
so  as  to  bend  the  artery  and  at  the  same  time  exercise  pressure  on  the 
tumor  itself.  The  circulation  through  the  sac  is  thus  greatly  lessened. 
The  flexed  posture  can  be  maintained  by  applying  a  collar  around  the 
limb  above  the  joint  and  another  below  it,  and  preventing  extension  by 
a  short  chain  attached  to  both.  A  more  simple  means  is  an  ordinary 
roller  bandage  applied  by  figure-eight  turns.  The  forced  flexion  should 
be  sufficient  to  check  pulsation  completely  in  the  sac,  but  the  joint  should 
not  be  flexed  to  such  an  acute  angle  as  will  make  too  violent  pressure  on 
the  aneurism  or  injure  the  articulation.     It  is  not  satisfactory  in  large 


\\  ai.-;..ii'.-  \',  uight  oiiuiiressor. 
The  dotted  line  indicates  the 
position  of  the  limb. 

to  cure  by  compression. 


ANEURISM, 


277 


aneurisms,  nor  in  those  tending  to  inflammation.  Rupture  or  suppura- 
tion may  be  induced  by  it  in  such  cases.  In  small  aneurisms  and  as  an 
adjuvant  to  digital  or  instrumental  compression,  flexion  has  a  value. 


Fig.  107. 


Briddon's  compressor. 

Cure  of  aneurism  at  the  elbow  or  knee  has  occasionally  been  obtained  by 
voluntary  maintenance  of  the  flexed  position.  So,  indeed,  has  digital 
compression,  of  the  interrupted  kind  exerted  by  the  patient's  own  fingers, 
effected  a  cure  of  aneurism. 

Fig.  108. 


Signorini's  tourniquet. 

The  last  method  of  employing  pressure  is  what  may  be  called  general 
compression,  and  is  accomplished  by  the  Esmarch  apparatus.  A  rubber 
bandage  is  applied,  as  in  preparing  for  amputation,  from  the  distal  ex- 


278 


DISEASES    OF    THE    ARTERIES. 


tremity  of  the  limb  to  the  lower  end  of  the  aueuiisin.  Tlie  surface  of 
the  aneurism  is  then  left  uncovered  and  another  elastic  bandage  firmly 
applied  above  it,  or  the  first  bandage  is  carried  loosely  around  the  loca- 
tion of  the  tumor  and  applied  tightly  to  the  limb  above.  Near  the  trunk 
the  application  of  tiie  bandage  is  discontinued  and  the  limb  is  encircled 
by  the  thick  elastic  band,  which  plays  the  ])art  of  a  tourni(iuet.  The  access 
of  blood  to  the  limb  is  thus  cut  off  and  the  other  bandage  or  bandages  are 
removed.  The  tumor,  however,  is  left  distended  with  fluid  blood  in  a 
state  of  rest,  which  soon  coagulates.  It  is  perhaps  well  to  delay  a  mo- 
ment when  the  elastic  bandage  has  been  applied  as  far  as  the  lower  end 
of  the  aneurism,  so  that  the  current  from  above  may  fully  distend  the 
sac  before  the  vessel  is  compressed  on  the  proximal  side  of  the  tumor. 
The  circulation  should  be  kept  out  of  the  limb  for  about  an  hour,  unless 
there  is  some  contra-indication.  Before  the  constricting  cord  is  removed 
comjiiete  digital  or  instrumental  pressure  should  be  made  u])on  the  artery 
above  it,  lest  the  sudden  current  wash  away  or  break  up  the  soft,  black 
clot  in  the  sac.  This,  or  moderate  compression  at  least,  should  be  kept 
up  for  a  few  hours  afterward  to  allow  the  clot  to  become  firmer.  Anaes- 
thesia will  be  required  when  the  Esmarch  apparatus  is  used. 

Fig.  100. 


Tufnell's  truss-like  compressor  applied.     (Erichsen.) 


If  the  aneurism  does  not  show  absence  of  pulsation  after  this  treatment, 
the  patient  should  be  let  alone  for  a  week  before  a  second  trial  is  made. 
In  the  meantime  efforts  to  increase  the  coagulability  of  the  blood  may  be 
carried  on.  These  have  been  described  under  the  medical  treatment  of 
aneurism.  General  compres.sion  seems  to  be  most  applicable  to  recent 
aneurisms  of  moderate  size  with  walls  that  are  not  very  thin.  It  is  to  be 
avoided  or  only  applied  with  extreme  caution  and  for  short  periods  in 
patients  whose  vessels  are  markedly  atheromatous.  Danger  of  inducing 
gangrene  is,  under  such  circumstances,  very  great. 


ANEUKISM.  279 

When  ligation  becomes  necessary,  after  failure  in  curing  by  the  Es- 
march  apparatus,  the  surgeon  should  not  attempt  to  apply  the  ligature  at 
the  point  where  the  constricting  band  encircled  the  limb.  The  peri-arte- 
rial structures  are  liable  to  be  infiltrated  or  inflamed  at  this  point.  A 
higher  or  lower  point  should  be  selected.  This  rule  should  be  followed 
in  ligating  after  any  form  of  compression  has  been  previously  employed. 

The  comparative  advantages  and  disadvantages  of  compression  in  the 
treatment  of  aneurism  claim  attention.  Though  not  without  risk  of  in- 
ducing erysipelas,  inflammation,  and  suppuration  of  the  sac,  thrombosis 
and  gangrene,  compression  is  safer  than  ligation.  This  is  probably  true, 
notwithstanding  the  fact  that  the  use  of  catgut  and  similar  aseptic  liga- 
tures has  reduced  very  greatly  the  risks  formerly  associated  with  ligation. 
Partial  compression  has,  however,  the  disadvantage  of  being  a  more  tedi- 
ous method  than  ligation,  and  is  not  available  when  the  patient  is  fretful 
or  the  disease  rapidly  increasing.  Neither  form  of  compression  is  to  be 
attempted  when  the  limb  is  inflamed  or  oedematous.  It  is  probable  that 
the  development  of  the  collateral  circulation  due  to  the  compression  acts 
at  times  as  a  source  of  failure  when  subsequent  ligation  is  demanded  by 
inefficacy  of  compression  as  a  means  of  cure.  On  the  other  hand,  the 
same  effect  may  be  a  preventative  of  gangrene  after  ligation,  especially 
in  the  old,  whose  arteries  are  not  well  fitted  to  carry  on  the  collateral  cir- 
culation after  ligation,  unless  previous  gradual  enlargement  has  been 
effected  by  compression. 

Compression  is  not  serviceable,  as  a  rule,  in  the  cure  of  fusiform 
aneurism. 

The  rules  for  emjoloying  compression  then  may  be  formulated  as  fol- 
lows :     Use  it : 

1.  In  aneurisms  of  recent  development  and  when  the  success  of  subse- 
quent ligation  is  not  much  imperilled  by  its  use. 

2.  When  ligation  is  especially  dangerous,  as  it  is  in  the  aged,  during 
epidemics  of  erysipelas,  and  in  certain  locations  of  the  body. 

3.  Experimentally  for  five  to  seven  days  in  nearly  all  cases. 

If  nothing  is  gained  by  compression  in  the  course  of  a  week,  it  is  usually 
proper  to  resort  to  ligation. 

Arterial  ligation  for  the  cure  of  aneurism  has  been  practised  in  four 
ways,  of  which  two  are  practically  valueless.  Of  the  two  remaining 
methods  one  is  always  preferred,  except  when  the  proximity  of  the 
aneurism  to  the  heart  renders  its  performance  exceedingly  dangerous. 
This  method  is  called  the  Huuterian  method.  It  consists  in  applying  a 
ligature  to  the  artery  between  the  aneurism  and  the  heart,  and  at  such  a 
distance  from  the  former  as  will  insure  the  existence  of  a  small  branch 
leaving  the  artery  between  the  ligature  and  the  seat  of  disease.  The 
ligature  on  being  tied  arrests  at  once  the  current  in  the  main  artery  and 
would  entirely  stop  the  blood  flow  through  the  aneurismal  sac,  if  the  small 
branch  mentioned  did  not  exist.  This  small  branch,  which  has  an  anasto- 
mosis with  branches  given  off  from  the  main  vessel  above  the  site  of  liga- 
tion, soon,  by  dilatation  and  reversal  of  current,  carries  a  small  amount 
of  blood  into  the  main  vessel  below  its  origin,  and  thence  through  the 
aneurismal  sac.  Thus,  it  is  seen  that  the  Hunterian  method  of  ligation 
does  not  entirely  arrest  the  current  through  the  sac,  but  merely  diminishes 
it  very  greatly,  Deposition  of  laminated  fibrine,  which  is  the  method  of 
spontaneous  cure  which  is  most  desirable,  is  thus  determined,  whereas 
entire  arrest  of  the  current  would  have  caused  the  formation  of  soft  clot 


280 


I'ISEASES    OF    THE    ARTERIES. 


iu  the  sac,  which  may,  it  is  true,  cause  final  solidification,  but  which  is 
apt  to  be  followed  by  inflammation  of  the  sac. 


Anastomosis  around  ligature,  giv- 
ing feeble  current  through  sac. 


Anastomosis    around    sao,   giving 
feeble  current. 


Strong  current  from   neighboring 
large  trunk. 


Diagram  <if  anastomosis  after  Hunterian  method  of  treating  aneurism. 

Of  the  three  other  methods  of  ligation  one  is  a  proximal  ligation,  that 
is,  on  the  side  of  the  disease  nearer  the  heart,  and  two  are  distal  liga- 
tions, that  is,  on  the  side  away  from  the  heart. 

Table  of  the  four  methods  of  ligation  in  treating  aneurism. 


Proximal  Ligations. 

Anel's.— Ligature  applied  close  above  aneurism  with  no  intervening 
branch. 
Objections:  1.  Difficult,  because  artery  is  overlapped  or  displaced  by 
sac. 

2.  Causes  total  arrest  of  blood  current,  hence  soft  clot 

and  tendency  to  inflammation  of  sac. 

3.  Artery  probably   atheromatous,    hence   tendency  to 

secondary  hemorrhage. 
Hunter's. — Ligature  applied  at  some  distance  above  aneurism,  so  as  to 
have  an  intervening  branch. 
Advantages:  1.  Easy  of  performance. 

2.  Causes  partial  arrest  of  blood   current,  hence   firm 

fibrinous  deposit. 

3.  Artery  much  more  likely  to  be  healthy. 


ANEUEISM, 


281 


Distal  Ligations. 

Brasdor's. — Ligature  applied  just  below  aneurism. 
Objections :  Same  as  in  Anel's. 

Wardrop's. — Ligature  applied  to  trunk  a  little  below  lirst  branch  or 
to  first  brancb  a  little  below  its  origin  from  the 
trunk. 
Advantages  :  Same  in  kind  as  those  of  Hunter's  method,  but  it  is  less 
successful  in  causing  solidification  because  current 
is  not  arrested  sufficiently.  Xever  used  except  in 
aneurism  of  innominate  or  of  root  of  common 
carotid  artery  and  then  it  is  adopted  because  the 
Hunterian  method  is  impossible. 

Fig. 111. 


Diagrams  showing  Anel,  Hunter,  Brasdor  and  Wardrop  methods. 

The  Hunterian  method  of  ligation  must  be  considered  more  fully,  since 
it  is  the  one  to  be  adopted  when  compression  is  deemed  impracticable. 
The  method  of  exposing  the  various  arteries  and  ligating  them  in  con- 
tinuity is  described  in  a  subsequent  section. 

When  the  catgut  cord  has  been  placed  under  the  vessel  and  before  the 
knot  is  tied  the  artery  should  be  compressed  between  the  cord  and  a 
finger  inserted  into  the  wound,  in  order  to  prove  by  absolute  arrest  of 
pulsation  in  the  tumor  that  the  supplying  artery  has  been  exposed.  Just 
before  the  ligature  is  drawn  tight,  it  is  well  to  make  pressure  for  half  a 
minute  upon  the  artery  on  the  distal  side  of  the  aneurism  in  order  that 
the  sac  may  be  fully  distended  with  blood  before  the  circulation  is 
arrested.  A  good  size  catgut  or  flat  silk  ligature  is  to  be  preferred.  With 
ligation  of  the  vessel,  pulsation,  thrill  and  murmur  in  the  tumor  imme- 
diately cease  and  the  limb  below  shows  some  elevation  of  temperature, 
which  usually,  however,  soon  subsides. 

Loss  of  muscular  power,  pain  and  hyperfesthesia  are  frequently  ob- 
served in  the  parts  below  the  site  of  operation.  The  tumor  at  first  feels 
softer  than  usual,  but  in  a  few  hours  becomes  harder  and  more  elastic. 
This  process  of  solidification  continues  and  in  a  few  days  is  completed  by 
the  transformatson  of  the  sac  into  a  hard  ball.  Contraction  then  begins 
and  in  the  course  of  several  weeks  or  months,  nothing  at  all,  or  nothing 


282  DISEASES    OF    THE    ARTERIES. 

but  a  slight  thickening,  is  perceptible  to  the  touch.  In  rare  instances 
some  enlargement  of  the  tumor  without  return  of  pulsation  may  occur 
after  ligation  from  influx  of  blood  from  the  distal  part  of  the  artery. 
This  is  apt  to  load  to  the  suspicion  that  a  malignant  muscular  growth  has 
been  mistaken  for  an  aneurism.  A  subsequent  solidiHeation  of  the  sac 
clears  up  the  doubt.     A  similar  condition  may  follow  compression. 

After  the  operation  the  limb  should  be  enveloped  in  cotton-wool  held 
in  position  by  a  bandage  loosely  applied,  and  the  patient  should  be 
directed  to  avoid  attempting  to  move  the  extremity,  (^uiet  should  be 
obtained  by  anodynes,  if  necessary.  The  cott(m  tends  to  preserve  an 
even  temperature,  and  protects  from  injurious  influences  the  parts  which 
have  now  a  diminished  circulatory  supply.  For  a  long  time,  even  after 
consolidation  of  the  tumor,  all  violent  exercise  of  the  extremities  should 
be  avoided.  Impairment  of  muscular  power,  liability  to  suflTer  from  ex- 
posure to  cold,  and  other  nutritive  defects  often  remain  permanently  after 
arterial  ligation  for  any  cause. 

The  Hunterian  method  of  ligation  is  usually  followed  by  the  develop- 
ment of  two  collateral  circulatory  arches :  one  between  the  branches 
above  the  ligature  and  those  given  off  between  it  and  the  aneurism,  and 
another  between  the  branches  below  the  aneurism  and  those  above  it. 
The  lower  anastomosis — namely,  that  around  the  aneurism,  is  generally 
established  more  rapidly  than  that  around  the  ligature,  because  the  col- 
lateral branches  in  the  former  region  have  previously  been  enlarged  by 
the  circulatory  interference  occasioned  by  the  pressure  of  the  aneurismal 
tumor.  This  double  anastomosis  is  due  to  the  fact,  that  the  artery 
usually  becomes  obliterated  at  the  seat  of  aneurism  as  well  as  at  the  seat 
of  ligation,  but  is  pervious  between  those  points.  If  the  sac  solidifies  and 
leaves  the  vessel  pervious  opposite  the  seat  of  aneurism,  or  if  the  vessel 
becomes  entirely  occluded  by  clot  or  obliterated  from  the  ligature  to  a 
point  below  the  aneurism,  only  one  collateral  arch  is  developed. 

Ligation  is  indicated  for  the  treatment  of  aneurism  : 

1.  When  compression  has  been  tried  unsuccessfully  and  when  com- 
pression cannot  be  aj)plied  ;  provided  that  the  disease  is  advancing  and  so 
located  that  the  application  of  the  ligature  is  not  attended  with  unusual 
risk. 

2.  When  the  aneurism  has  ruptured  and  caused  hemorrhage  into  an 
articulation  or  into  the  intermuscular  spaces  ;  provided  that  the  condi- 
tion does  not  <lemand  amputation. 

3.  When  ru})ture  into  one  of  the  cavities  of  the  body  or  upon  the 
surface,  or  the  possibility  of  an  early  occurrence  of  such  rupture  threatens 
to  destroy  life  by  hemon-hage. 

Ligation  is  contra-indicated  : 

1.  When  the  locality  of  the  aneurism  is  such  that  compression  can  be 
applied. 

2.  When  the  operation  is  peculiarly  dangerous  on  account  of  the  loca- 
tion of  the  aneurism,  the  existence  in  the  ])atient  of  extensive  arterial  or 
cardiac  disease,  or  the  prevalence  of  erysipelas  or  pyaemia. 

3.  When,  on  account  of  the  proximity  of  large  anastomosing  branches 
or  from  any  other  circumstances,  the  operation  would  probably  be  unsuc- 
cessful. Under  such  circumstances  ligation  is  justified  only  ])y  impending 
rupture. 

The  complications  likely  to  arise  after  ligation,  which  may  interfere 
with  the  successful  solidification  of  the  aneurism  or  tend  to  destroy  the 
patient's  life,  are  :  recurrent  pulsation  in  the  tumor,  secondary  hemor- 


ANEURISM.  283 

rhage  at  the  site  of  operation,  suppurative  and  gangrenous  inflammation 
of  the  sac,  gangrene  of  the  extremity,  pysemia,  and  in  special  locations, 
secondary  disease  of  the  brain  or  thoracic  viscera. 

Recurrent  pulsation  is  due  to  the  anastomotic  arch  around  the  ligature 
allowing  too  free  a  blood-current  to  enter  the  artery  between  the  ligature 
and  the  aneurism.  An  anomalous  distribution  of  the  branches  or  abnor- 
mally large  size  of  the  usual  branches,  is  the  cause  of  this  undesirable 
freedom  of  the  collateral  current.  The  employment  of  the  compression 
treatment  for  a  considerable  period  previous  to  resort  to  ligation,  is  at 
times  an  agent  in  developing  unusually  free  anastomosis.  Recurrent 
pulsation  develops  within  twenty-four  hours,  and,  if  slight,  is  not  likely 
to  interfere  with  progressive  consolidation  of  the  tumor.  If  it  increases 
in  force  in  the  succeeding  few  days  and  the  tumor  remains  soft  and  with- 
out diminution  in  size  or  shows  evidence  of  enlargement,  the  operation  is 
proved  to  have  been  unsuccessful,  and  other  means  of  cure  must  soon  be 
adopted.  Recurrence  of  pulsation  after  the  lapse  of  several  months  is 
almost  certainly  due  to  the  development  of  a  new  aneurism,  near  the  site 
of  the  cured  aneurism. 

Recurrent  pulsation  should  be  treated  by  elevation  of  the  limb  and 
moderate  compression  of  the  tumor  and  of  the  artery  above  the  site 
of  ligation,  success  will  probably  follow  ;  if  not,  continued  progress  of 
the  disease  will  demand  Anel's  method  of  ligation,  incision  of  the  sac 
and  double  ligature,  or  amputation. 

Secondary  hemorrhage  may,  after  the  lapse  of  one  or  two  weeks,  occur 
from  the  wound  made  at  the  time  of  ligation.  This  is  due  sometimes  to 
an  atheromatous  condition  of  the  artery  preventing  proper  healing  of  the 
vascular  coats  divided  by  the  ligature.  At  other  times,  it  is  caused  by  a 
large  branch  being  given  off*  so  near  the  site  of  ligation  that  the  collateral 
current  coming  through  it  into  the  main  trunk  exerts  too  much  pressure 
for  successful  resistance  by  the  short  internal  clot. 

Secondary  hemorrhage  is  more  frequent  in  the  upper  than  in  the  lower 
extremity,  because  the  anastomosis  is  more  free.  As  rapidity  of  union 
of  the  wound  is  a  barrier  to  secondary  hemorrhage,  strict  asepsis  and 
antisepsis  have  made  secondary  hemorrhage  very  uncommon  after  ligation 
for  aneurism.  The  flat  ligature  of  animal  nerve  or  tendon,  which  merely 
approximates  the  arterial  walls  without  dividing  the  internal  and  middle 
coats,  will  probably  be  found  by  future  experiment  to  be  the  safest  means 
of  ligating  atheromatous  vessels. 

When  secondary  hemorrhage  occurs,  it  should  be  treated  by  pressure 
made  upon  and  in  the  wound  by  compression  with  plugs  of  sponge,  or  fine 
shot.  If  this  fails  the  Esmarch  apparatus  should  be  applied,  the  wound 
opened  freely  and  the  artery  ligated  above  and  below  the  former  ligature. 
In  the  event  of  the  bleeding  still  continuing  ligation  of  the  artery  in  con- 
tinuity at  a  higher  point  is  good  practice  in  the  upper  extremity,  but  is 
very  likely  to  be  followed  by  gangrene  if  done  in  the  lower  extremity, 
where  the  establishment  of  sufficient  collateral  circulation  is  unusual. 
Amputation  is,  therefore,  usually  preferable  in  persistent  secondary  hemor- 
rhage occurring  after  ligation  for  aneurism  of  the  leg  or  thigh.  If  the 
second  ligation  in  continuity  is  done  in  either  extremity,  such  a  point 
must  be  selected  as  will  permit  subsequent  amputation  if  this  becomes 
necessary.  Occasionally  it  is  possible  to  control  secondary  hemorrhage 
by  ligating  in  continuity  the  branch  through  which  the  blood  finds  its  way 
into  the  distal  portion  of  the  trunk  originally  tied. 

Suppurative  or  gangrenous  inflammation  of  the   sac  may  result  from 


284  DISEASES    OF    THE    ARTERIES. 

recurrent  pulsation,  from  incomplete  anastomosis  around  the  aneurism, 
from  complete  arrest  of  circulation  in  the  sac  and  consequent  formation  of 
soft  clot,  from  the  great  size  and  thinned  walls  of  the  sac,  and  from  exter- 
nal violence,  such  Jis  may  be  sustained  by  rough  handling  or  kneading  of 
the  tumor  cither  before  or  after  ligation.  The  symptoms  of  inHammation 
of  the  sac  are  those  characteristic  of  a  similar  process  elsewhere.  Suppu- 
ration is  exhibited  by  the  (ordinary  signs  of  abscess.  When  an  opening 
has  occurred  spontaneously  or  by  incision,  hemorrhage  becomes  a  promi- 
nent symptom.  If  recurrent  pulsation  has  existed,  the  bleeding  will  be 
immediate  and  profuse;  under  other  circumstances  the  escape  of  blood 
may  not  occur  for  several  days,  and  at  first  will  probably  seem  insignifi- 
cant. Suppuration  or  sloughing  occurring  even  so  late  as  six  or  eight 
weeks  after  ligation  may,  especially  if  accompanied  by  recurrent  pulsation, 
be  followed  by  fatal  hemorrhage. 

Suppuration  of  the  sac  is  to  be  treated  by  at  once  applying  a  provisional 
tourniquet  to  the  artery  above  the  seat  of  ligation  and  laying  open  the 
abscess.  If  bleeding  occurs  the  surgeon  should  proceed  to  turn  out  the 
clot,  securing  dangerous  points  by  ligature  or  the  actual  cautery,  make  the 
wound  antiseptic,  pack  it,  and  wait  for  it  to  heal  by  granulation.  Sponge 
grafting  would  probably  hasten  cicatrization  by  causing  granulations  to 
fill  the  cavity  more  promptly.  The  patient  must  be  constantly  watched  by 
competent  surgical  attendants,  so  that  on  the  first  sign  of  bleeding  the 
arterv  can  be  controlled  by  digital  compression,  or  by  screwing  down  the 
pad  of  the  tourniquet,  which  is  kept  loosely  applied.  If  hemorrhage  per- 
sists, amputation  should  not  be  long  delayed  by  experiments  with  tem- 
porizing measures. 

Gangrene  of  the  limb  is  a  formidable  complication  of  ligation.  Its 
occurrence  may  be  due  to  rigidity  of  the  arterial  branches  j^reventing 
sufficient  enlargement  for  the  establishment  of  collateral  circulation,  to 
pressure  of  the  tumor  upon  the  anastomosing  branches,  to  injury  of  the 
main  venous  trunk  at  the  time  of  ligating  the  artery,  and  to  exposure  of 
the  limb  to  heat,  cold,  or  undue  pressure  soon  after  the  operation.  This 
complication  arises  within  the  first  week  or  ten  days,  and  is  more  frequent 
in  the  lower  than  in  the  upper  extremity.  The  form  is  generally  that  of 
moist  gangrene  because  venous  obstruction  is  usually  one  of  the  factors  in 
its  etiology.  Wrapping  the  limb  in  cotton  to  keep  the  temperature  equable 
and  to  avoid  injury,  and  slightly  elevating  it  to  encourage  venous  return 
are  measures  calculated  to  lessen  the  probability  of  gangrene.  Gentle 
friction  of  the  limb  toward  the  body  may  sometimes  be  used  to  accelerate 
the  venous  blood  current.  When  gangrene  has  begun  after  arterial  liga- 
tion, but  little  can  be  done  except  promptly  to  amputate  the  limb  high 
up.  In  the  upper  extremity  removal  at  the  shoulder-joint,  in  the  lower 
removal  at  the  junction  of  the  middle  and  upper  thirds  of  the  thigh  will 
probably  be  necessary.  Occasionally  laying  open  the  sac  and  turning 
out  all  clots  will  relieve  venous  obstruction  and  restrain  the  progress  of 
gangrene. 

Gangrene  of  a  similar  character  may  follow  the  employment  of  com- 
pression for  the  cure  of  aneurism. 

Pytemia  may  follow  ligation,  and  is  more  frequent  in  patients  who  have 
previously  suffered  from  hemorrhage  or  other  depressing  influences. 
Finally  ligations  of  vessels  near  the  body  may  be  complicated  with 
pleurisy,  peritionitis,  and  other  unfortunate  sequences,  due  to  injury  at  the 
time  of  operation,  or  to  spreading  of  inflammation.     The  fatal  issue  after 


LIGATION    OF    ARTERIAL    TRUNKS. 


285 


ligation  of  the  common  carotid  artery  may  be  due  to  cerebral  anemia  or 
thrombosis. 

Suppuration  and  septicasmic  or  sapraemic  processes  occurring  in  connec- 
tion with  aneurism  are,  of  course,  due  to  the  same  vegetable  parasites  as 
cause  these  conditions  in  other  surgical  wounds  or  diseases.  The  bacteria 
either  gain  access  by  the  wound  made,  or  while  circulating  in  the  blood 
or  lymj^h  streams,  are  arrested  and  find  a  place  of  least  resistance  in  the 
tissues  where  the  aneurism  exists. 


Ligation  of  Arterial  Trunks  in  Continuity. 


Arteries  are  tied  in  their  continuity  to  lessen  the  circulation  through 
aneurismal  tumors  and  to  arrest  secondary  hemorrhage,  which  pressure 
or  ligation  in  the  wound  has  failed  to  control.  The  special  instruments 
required  for  the  operation  are  a  bistoury  or  scalpel,  dissecting  forceps,  a 
grooved  director,  two  metallic  retractors  with  which  to  hold  the  margins 
of  the  incision  apart,  an  aneurism  needle,  and  a  strong  antiseptic  ligature 
of  catgut,  ox-tendon,  or  nerve. 

Fig  112. 


Grooved  director. 
Fia.  113. 


Aneurism  needle. 
Fig.  114. 


Blunt  and  sharp-pointed  retractors. 

The  surgeon  must  first  of  all  determine  the  exact  course  of  the  artery 
by  the  well-known  landmarks  of  clinical  anatomy  and  the  linear  guides 
which  are  based  upon  these  relations.  If  the  artery  is  a  superficial  one 
its  pulsation  will  aid  in  this  determination.  If  a  superficial  tendon  or 
muscle  is  one  of  the  guides,  it  can  be  made  to  stand  out  prominently  by 
getting  the  patient,  before  etherization,  to  use  it  voluntarily.  The  line  of 
the  tendon  or  artery  can  then  be  marked  on  the  skin  with  a  moistened 
aniline  pencil.  In  operating  on  the  dead  body  such  tendons  are  made 
prominent  by  moving  the  joints  in  such  a  manner  as  to  bring  tension  on 


286  DISEASES    OF    THE    ARTERIES. 

the  muscular  fibres.  For  example,  if  a  flexor  is  the  guide  ask  the  patient 
to  fiex  the  joint,  and  the  muscle  will  on  contraction  become  prominent ; 
but  in  the  surgical  laboratory  the  same  muscle  in  the  cadaver  can  only 
be  rendered  prominent  by  forcibly  extending  the  joint. 

The  second  step  is  to  decide  upon  the  point  of  ligation.  In  secondary 
hemorrhage  it  is  the  best,  if  practicable,  to  expose  and  tie  the  vessel  near 
the  wound  and  on  both  sides  of  it.  In  the  case  of  aneurism  the  Hun- 
terian  method  is  usually  the  be^t.  This  places  the  ligature  sufficiently 
far  from  the  aneurism  to  insure  at  least  one  ■<mall  branch  being  given  off 
by  the  trunk  between  the  site  of  ligation  and  the  aneurism.  The  ligature 
should  always  be  applied  at  least  one-half  or  three-fpiarters  of  an  inch 
below  the  origin  of  anv  large  branch  or  bifurcation  of  the  artery.  When 
this  is  anatomically  impossible  it  is  often  wise  to  secure  the  branch  also 
with  a  ligature  to  prevent  secondary  hemorrhage,  which  otherwise  may 
result  from  the  forcible  collateral  current  developed  in  the  branch  or  bi- 
furcation. 

The  incision  in  most  instances  should  be  made  slightly  oblique  to  the 
course  of  the  artery  and  with  its  centre  over  the  point  chosen  for  ligation. 
Such  an  obliquity  of  ten  degrees  makes  it  much  more  easy  to  search  for 
the  muscular  interspaces  and  other  deep  guides  leading  to  the  vessel. 
The  skin  should  be  stea<lied,  but  not  displaced,  l)y  the  thumb  and  fingers 
of  the  left  hand  while  the  point  of  the  knife  is  inserted  perpendicularly 
through  the  skin  and  an  incision  varying  from  two  to  five  inches  in 
'length  is  made  with  one  sweep.  The  scalpel  should  be  brought  out  per- 
pendicularly in  order  that  the  wound  may  be  of  one  depth  throughout 
its  entire  length.  The  incision  should  always  be  sufficiently  long  to  aftbrd 
free  access  to  the  tissues  beneath.  When  the  artery  is  deeply  located, 
whether  from  its  anatomical  relations  or  the  obesity  of  the  patient,  a  long 
incision  is  demanded.  The  superficial  fascia  may  be  divided  at  the  same 
time  as  the  skin,  if  the  vessel  lies  below  the  deep  fascia.  Large  super- 
ficial veins  should  be  drawn  aside,  if  convenient,  though  their  division  is 
of  little  importance  since  the  bleeding  is  easily  arrested  by  hemostatic 
forceps  or  ligatures  if  it  does  not  cease  spontaneously.  The  deep  fascia 
is  to  be  incised  in  a  similar  manner  as  the  skin,  or  it  may  be  punctured 
and  a  grooved  director  slipped  under  it,  after  which  manoeuvre  it,  is 
divided  by  carrying  the  inverted  knife  along  the  groove.  The  original 
length  of  the  incision  should  be  maintained  until  the  sheath  of  the  artery 
is  reached.  If  the  deep  fascia  is  so  tense  as  to  prevent  satisfactory  inves- 
tigation of  the  parts  beneath,  a  short  incision  may  be  made  across  the 
middle  of  the  longitudinal  one. 

Muscular  interspaces  are  guides  to  some  of  the  arteries.  These,  on 
account  of  the  fat  deposited  in  them,  are  usually  (juite  readily  recognized 
as  yellow  lines.  Sometimes  this  yellow  appearance  is  seen  before  the 
deep  fascia  is  divided.  Another  guide  to  them  is  furnished  by  the  small 
vessels  which  ramify  in  them  and  perforate  the  fascia  covering  them. 
The  proper  muscular  interspaces  to  gain  access  to  the  artery  are  next  torn 
open  with  the  rounded  end  of  the  director ;  or  the  wound  is  deepened  by 
the  careful  use  of  the  scalpel.  As  the  situation  of  the  artery  is  approached 
the  forceps  and  the  back  of  the  scalpel's  point  are  the  safest  means  of 
separating  the  tissues.  During  this  dissection  the  wound  may  be  held 
open  by  blunt  hooks  or  retractors,  and  the  bulging  muscles  relaxed  by 
bending  the  joints. 

The  larger  arteries,  with  the  accompanying  vein  or  veins,  are  enclosed 
in  a  distinct  fibrous  sheath.     This  sheath  is  to  be  opened  by  pinching  up 


LIGATION    OF    ARTEEIAL    TRUNKS  287 

a  fold  with  small  toothed  forceps  and  making  in  it  with  the  knife  a  cut 
about  a  quarter  of  an  inch  long.  While  the  forceps  holds  the  edge  of 
the  opening  the  end  of  the  grooved  director  or  aneurism  needle  is  intro- 
duced into  the  sheath  on  one  side  of  the  artery  and  used  to  break  up  the 
adhesions  between  the  vessel  and  the  sheath,  or  the  adjacent  contents  of 
the  sheath.  By  a  similar  manoeuvre  on  the  other  side  of  the  vessel  com- 
plete isolation  of  the  same  is  accomplished.  Isolation  of  smaller  arteries 
which  have  no  distinct  sheath  can  be  readily  performed  by  using  two 
pairs  of  forceps  to  pull  away  the  small  veins  and  cellular  tissue.  The 
use  of  the  point  of  the  knife  is  dangerous  in  cleaning  the  artery,  lest  a 
puncture  be  inflicted  upon  the  artery  or  vein.  Care  must  be  observed 
with  the  blunt  instruments  that  undue  bruising  is  not  done. 

The  Esmarch  apparatus  is  sometimes  applied  to  prevent  obscuration  of 
the  parts  by  hemorrhage  during  the  operation.  Usually  it  is  unnecessary, 
for  only  a  few  small  branches  are  divided.     These  can  be  tied,  if  necessary. 

It  is  well  to  remember  the  characteristics  of  an  artery  in  the  living 
subject.  It  has  a  pinkish-white,  smooth,  shining  surface,  and  is  compres- 
sible, feeling  as  it  is  rolled  under  the  finger-tips  as  if  two  surfaces  were 
slipping  upon  each  other.  A  nerve  has  not  this  smooth,  shining  surface, 
but  has  longitudinal  markings,  due  to  its  fibrous  structure,  and  rolls 
under  the  fingers  as  a  solid  non-compressible  cord.  A  vein  is  purplish, 
soft,  and  flaccid,  and  from  its  distention  with  dark  blood  resembles  a  leech 
in  appearance.  It  becomes  more  distended  if  pressure  is  made  on  its  car- 
diac end.  A  small  tendon  is  pearly  white  and  glistening,  and  gives,  when 
seized,  the  impression  of  great  density.  Passive  motion  of  the  neighbor- 
ing joint  may  prove  its  identity.  The  recognition  of  the  artery  is  often 
aided  by  its  location  between  two  satellite  veins  and  by  its  pulsation. 
Pulsation,  however,  may  be  absent,  because  exposure  and  manipulation 
sometimes  cause  ai'teries  to  contract  and  become  temporarily  pulseless. 
On  the  other  hand,  a  deceptive  pulsation  may  be  transmitted  to  nervous 
or  fascial  bands  lyiug  over  an  artery.  When  the  operator  fails  to  find 
the  artery  he  should  not  tear  up  the  tissue  in  an  aimless  manner,  but 
should  at  once  review  all  the  steps  of  the  operation  and  systematically 
verify  each  landmark  from  the  surface  downward.  In  this  way  he  will 
discover  the  source  of  error. 

After  the  artery  has  been  recognized  and  isolated  the  end  of  the  curved 
aneurism  needle,  threaded  with  antiseptic  catgut  or  silk  is  carefully  passed 
around  it  without  disturbing  its  surroundings  or  pulling  it  from  its  bed. 
Chromicized  gut  is  better  for  large  vessels  than  plain  gut  since  it  is  not  so 
quickly  absorbed.  This  is  best  done  by  grasping  the  tissues  at  one  side 
of  the  artery,  but  not  the  artery  itself,  with  the  forceps  and  insinuating 
the  aneurism  needle  with  a  curvilinear  movement  under  the  artery  from 
that  side.  A  little  lateral  movement  of  the  point  of  the  needle  will 
render  its  passage  more  easy.  As  the  point  projects  at  the  opposite  side 
of  the  vessel  the  tissue  overlying  it  may  be  torn  through  with  the  finger- 
nail or  forceps,  if  it  is  seen  not  to  be  a  vein  or  part  of  the  arterial  wall. 
When  the  loop  of  ligature  in  the  eye  of  the  needle  is  visible  it  is  drawn 
out  of  the  wound  by  the  forceps  while  the  needle  is  made  to  retrace  its 
course  under  the  vessel  and  is  thus  removed. 

If  the  artery  has  a  single  vein  alongside  of  it  the  needle  should  be  in- 
troduced at  the  venous  side,  of  the  artery,  since  puncture  of  the  thin- 
walled  veins  is  thus  less  likely  to  occur  than  when  the  point  of  the  needle 
is  carried  beneath  the  vessel  from  the  side  opposite  to  the  vein.  If  accom- 
panying veins  exist    on  both  sides  of  the  artery  this  precaution  loses  its 


288 


DISEASES    OF    THE    ARTERIES. 


value.  If  by  accident  such  a  large  vein  is  punctured  during  the  opera- 
tion, it  may  be  well  to  extend  the  incision  and  tie  at  a  higher  point  of  the 
artery.  Bleeding  from  the  vein  is  to  be  controlled  by  lateral  ligation  or 
suture  of  the  vein,  if  any  venous  hemorrhage  of  importance  occurs.  Be- 
fore tying  the  ligature  the  surgeon  should  hold  the  artery  in  the  loop  of 
the  string  and  compress  it  with  a  finger  to  be  sure  that  pulsation  below  is 
arrested  by  constriction  of  the  structure  encircled.    This  manoeuvre  proves 

Fig.  115. 


Diagram  of  openinc;  slieath  of  artery,  passing  ligature  and  tying  ligature.     (Bryant.) 

or  disproves  the  proper  application  of  the  ligature,  which  may  be  around 
the  wrong  artery  or  perchance  around  a  nerve  or  ])iece  of  fascia.  The 
ligature  should  be  secured  by  a  friction  knot  or  a  ilat  knot;  and  in  the 
latter  case  it  is  well  to  tie  the  ends  a  third  time  after  completing  the 
ordinary  double  tie,  for  the  catgut  is  apt  to  become  loosened.  During  the 
knotting  the  index  fingers  should  be  carried  into  the  depth  of  the  wound 
in  order  not  to  raise  the  vessel  from  its  bed.  Sufficient  tension  should  be 
put  upon  the  first  tie  to  insure  division  of  the  inner  and  middle  coats  of 
the  artery.  This  is  known  by  the  sensation  of  cutting  into  the  wall  that 
is  felt  by  the  operator  as  the  noose  is  tightened.  AVhen  mere  approxima- 
tion of  the  inner  tissue  is  desired,  this  cutting  is  avoided  by  using  flat  liga- 
tures of  ox  aorta  or  nerve.  After  ligation  is  accomplished  the  wound  is 
approximated  with  sutures,  cotton  is  applied  around  the  limb  to  maintain 
an  equable  temperature,  and  the  extremity  is  slightly  raised  to  encourage 
venous  return.  The  wound  mu.st  be  kept  bacteria-free  so  that  septic  and 
purulent  infection  may  be  with  certainty  avoided. 


Ligations  of  Special  Arteries. 


Certain  of  the  arteries  are  ligated  in  continuity  with  comparative  fre- 
quency. The  most  eligible  site  for  such  ligations  must  be  mentioned  and 
the  successive  steps  described.     The  unusual  operations  will  be  omitted. 


BRACHIAL    ARTERY. 

Eadial  and  Ulnar  Arteries. — These  vessels  are  seldom  tied,  except 
at  the  wrist.  If  deligatiou  at  a  higher  point  of  either  artery  is  demanded, 
the  surgeon  usually  prefers  to  secure  the  brachial.  The  radial  artery 
above  the  wrist  lies  between  the  tendons  of  the  radial  flexor  of  the 
carpus  and  the  long  supinator,  immediately  below  the  deep  fascia  and 
upon  the  square  pronator.  Its  direction  and  site  are  indicated  by  a 
line  drawn  from  the  middle  of  the  bend  of  the  elbow  to  the  inner  side 
of  the  styloid  process  of  the  radius.  An  incision  one  and  a  half  to  two 
inches  in  length  midway  between  and  parallel  to  the  radial  flexor  and  the 
long  supinator  will  expose  the  vessel  with  its  satellite  veins.  The  deep 
fascia  must  be  divided  with  care  or  the  artery  may  be  w^ounded.  The 
pulsation  of  the  artery  is  readily  felt  before  the  skin  is  incised. 

Fir.  llfi. 


Ligation  of  radial  and  ulnar  artery.     (Brtaxt.) 

The  ulnar  artery  at  the  wrist  lies  under  the  radial  border  of  the  tendon 
of  the  ulnar  flexor  of  the  carpus  and  between  it  and  the  superficial  flexor 
of  the  fingers.  The  vessel  lies  under  a  layer  of  fascia  situated  below  the 
tendon ;  hence,  it  is  necessary  to  divide  two  layers  of  deep  fascia  before 
reaching  it.  The  ulnar  nerve  is  situated  at  the  ulnar  side  of  the  artery 
and  close  to  it.  The  course  of  the  lower  portion  of  this  arterv  is  indi- 
cated by  a  line  drawn  from  the  inner  condyle  of  the  humerus  to  the  radial 
side  of  the  pisiform  bone.  The  surgeon  may  depend  upon  this  line  for 
determining  his  incision,  or  may  recognize  the  j)osition  of  the  tendon 
of  the  ulnar  flexor  of  the  carpus  by  its  insertion  into  the  pisiform  bone, 
and  make  an  incision  of  one  and  a  half  or  two  inches  along  its  radial 
margin.  The  glistening  tendon,  uncovered  after  dividing  the  deep  fascia, 
should  be  drawn  from  the  middle  line  of  the  arm,  when  the  second  pro- 
cess of  deep  fascia  will  be  exposed.  This  must  be  opened  before  the  artery 
is  reached  unless  it  has  an  anomalous  course  above  the  fascia.  It  is  usual 
to  pass  the  aneurism  needle  first  between  the  artery  and  the  nerve. 

Brachial  Artery. — The  brachial  artery  in  the  middle  of  the  arm 
lies  along  the  inner  border  of  the  biceps  ;  and  upon  the  coraco-brachial, 
the  anterior-brachial  muscles,  and  the  inner  head  of  the  triceps. .  The 
median  nerve  passes  over  it,  though  occasionally  under  it,  from  without 
inward.  A  satellite  vein  is  to  be  seen  on  each  side  of  the  vessel,  and  the 
large  basilic  vein  not  far  distant  internally.  A  line,  drawn  from  the 
junction  of  the  anterior  and  middle  thirds  of  the  axilla  to  the  middle  of 
the  bend  of  the  elbow,  indicates  its  course  with  accuracy.  Its  pulsation 
is  easily  felt.  An  incision  two  and  one-half  or  three  inches  in  length  is 
to  be  made  along  the  inner  side  of  the  biceps ;  when  the  deep  fascia  has 
been  divided,  the  muscular  fibres  of  its  margin  will  be  fully  exposed. 
Alongside  of  or  under  the  edge  of  this  muscle  will  be  seen  the  median 

19 


290 


DISEASES    OF    THE    ARTERIES. 


nerve,  which  is  then  drawn  aside  to  reveal  the  artery  lying  beneath  it. 
The  nerve  often  shows  marked  transmitted  pnlsation.  Sometimes  the 
artery  is  more  superficial  than  the  nerve.  The  arm  should  at  this  stage 
be  flexed  at  the  elbow  to  relax  the  belly  of  the  bice[)S.  It  is  usually 
better  to  have  an  assistant  hold  the  arm  than  to  allow  it  to  lie  upon  the 
table,  because  such  pressure  displaces  the  artery  and  pushes  up  the  triceps, 
which  may  be  mistaken  for  the  biceps.  The  edge  of  the  biceps  should 
always  be  uncovered  and  identified;  if  it  is  not,  the  surgeon  may  work 
too  far  inward  and  backward  and  become  confused  by  mistaking  the  ulnar 
nerve  for  the  median,  and  the  basilic  vein  for  the  artery.  The  vessel  is 
to  be  sought  at  or  under  the  edge  of  the  biceps  in  an  outwai'd  rather  than 
an  inward  direction. 

Fig.  117. 


Sice^is    muscle 


jSIedian  xeri'e 

Tendinous  JJlionein-ofis 
flii'ided 


Ligation  of  brachial  artery.    (Bryant.) 

Since  the  brachial  artery  is  not  infrequently  double  or  perhaps  bifur- 
cates into  the  radial  and  ulnar  up  near  the  axilla,  it  is  important  that  the 
surgeon  remember  this  possible  anomaly,  and  ascertain  that  he  has  secured 
that  vessel  which  will  diminish  the  blood-supply  as  he  desires. 

Axillary  Artery. — The  third  portion  of  this  vessel  can  be  reached 
with  safety  and  ease.  If  ligation  at  a  higher  point  is  demanded  by  the 
exigencies  of  the  disease,  it  is  better  perhaps  to  secure  the  third  portion 
of  the  subclavian  than  to  attempt  ligating  the  first  or  second  portion  of 
the  axillary. 

The  last,  or  third  portion  of  the  axillary  artery,  beginning  at  the  lower 
edge  of  the  lesser  ])ectoral  muscle,  lies  along  the  inner  border  of  the 
coraco-brachial  muscle.  The  median  and  musculo-cutaneous  nerves  lie 
on  the  outer  side  of  the  artery  ;  the  ulnar  and  internal  cutaneous  nerves 
and   the  axillary  vein  on  the  inner  side.     Sometimes  there  is  a  satellite 


SUBCLAVIAN    ARTERY. 


291 


vein  on  each  side  of  the  artery  instead  of  the  single  large  axillary  vein 
on  its  inner  side,  which  is  replaced  by  the  continuance  upward  of  the 
basilic  vein. 

A  line  drawn  from  the  junction  of  the  anterior  and  middle  third  of  the 
axillary  fossa  to  the  middle  of  the  bend  of  the  elbow,  gives  the  course  of 
this  portion  of  the  axillary  and  the  greater  portion  of  the  brachial 
artery. 

Fig.  118. 

Ceraca-Trrachial . '  ■muscJe- 


Ligation  of  axillary  artery.     (Bryant.)! 

When  the  arm  is  placed  at  a  right  angle  with  the  body  the  muscular 
margins  of  the  axillary  pit  are  prominently  shown.  AVith  the  limb  in 
this  position  an  incision  three  or  three  and  one-half  inches  long  should  be 
made  parallel  to  the  anterior  boundary  of  the  axilla,  and  about  one  third 
the  width  of  the  axillary  space  behind  this  boundary ;  or,  in  other  words, 
directly  over  the  head  of  the  humerus  and  a  little  oblique  to  the  line 
given  above.  The  edge  of  the  coraco-brachial  muscle  will  be  exposed. 
From  this  the  operator  searches  in  an  inward  direction,  finding,  first  the 
median  and  perhaps  the  musculo-cutaneous  nerves,  and  then  the  artery, 
with  the  axillary  vein,  the  ulnar  and  internal  cutaneous  nerves  on  the 
inner  side. 

The  nerves,  which  var}^  somewhat  in  their  relations,  may  be  mistaken 
for  the  artery.  Occasionally  a  muscular  slip  from  the  broad  dorsal  muscle 
crosses  the  artery.  It  is  recognized  by  the  transverse  direction  of  its 
fibres.  The  ligature  must  be  passed  from  within  outward,  and  should  not 
be  applied  near  the  origin  of  the  subscapular  artery. 

Subclavian  Artery. — The  third  portion  of  this  artery  extends  from 
the  outer  margin  of  the  anterior  scalene  muscle  to  the  outer  or  lower 
border  of  the  first  rib,  and  is  the  only  part  of  the  vessel  that  can  be 
ligated  with  comparative  safety.  It  is  situated  in  the  triangle  bounded 
by  the  clavicle  and  the  sterno-mastoid  and  omo-hyoid  muscles ;  lying 
against  the  first  rib,  the  anterior  scalene  muscle  and  brachial  plexus  of 
nerves.  The  subclavian  vein  is  situated  below  and  in  front  of  the  artery, 
from  which  it  is  separated  by  the  insertion  of  the  anterior  scalene  muscle 
into  the  tubercle  of  the  first  rib. 

To  ligate  the  artery  in  its  third  position  proceed  as  follows  :  Depress 
the  patient's  shoulder,  turn  his  head  in  the  opposite  direction,  and  draw 
the  skin  of  the  supraclavicular  fossa  downward  upon  the  clavicle  with 


202 


DISEASES    OF    THE    ARTERIES. 


the  left  hand  and  hold  it  there.  Then  make  an  incision,  three  or  four 
inches  in  length,  upon  the  clavicle  and  following  its  curves,  heginning  a 
half  inch  from  the  sterno-clavicular  joint.  The  tissues  should  l)e  divided 
down  to  the  periosteum.  AVhen  the  left  hand  ha.<  released  its  traction, 
the  skin  will  slide  upward  and  the  incision  will  be  located  about  half  an 
inch  above  the  clavicle.  Tliis  manipulation  of  the  skin  preserves  the 
external  jugular  vein  from  division  by  the  incision.  The  wound  should 
now  be  deepened  by  dividing  the  deep  fascia  and  cutting  the  edges  of  the 
sterno-mastoid  and  trapezius  muscles,  if  they  prevent  the  wound  being 
continued  deeper  with  its  original  length.  The  fibres  of  the  platysma 
myoid  muscle  in  the  superficial  fascia  will  be  noticed  during  the  dissec- 
tion. If  the  external  jugular  vein  cannot  be  held  out  of  the  way  with  a 
hook,  it  is  to  be  divided.  A  ligature  should  be  placed  also  at  the  cardiac 
side  of  the  proposed  section  before  the  division  is  made,  lest  air  be  sucked 
into  the  heart.  As  the  wound  is  carefully  deepened  the  surgeon's  finger 
.seeks,  at  its  inner  corner,  the  edge  of  the  anterior  scalene  muscle  as  it  goes 
down  to  its  insertion  into  the  first  ril>.  The  tubercle  of  insertion  is  often 
poorly  developed,  but  the  direction  of  the  fibres,  and  possibly  the  ex- 
posure of  the  phrenic  nerve  running  obliquely  over  the  muscle,  will  serve 
to  diflferentiate  it  from  other  structures. 

Fig.  119. 


ScaJen  ufA.  TiHcua 


Ligation  oi'  sul)c]avian  arterv.     (Bryant.) 


If  the  omohyoid  muscle  or  brachial  ])lexus  is  recognized  before  the 
anterior  scalene  is  seen,  the  search  should  be  made  in  a  direction  down- 
ward and  inward  from  those  landmarks.  The  artery  is  finally  uncovered 
bevond  the  outer  border  of  the  anterior  scalene  by  oi)ening  with  the  for- 
ceps or  director  a  layer  of  fascia  extending  over  the  vessel  from  this 
muscle.  The  artery  lies  at  a  depth  of  from  one  to  three  inches  from  the 
surface  and  runs  in  a  downward  and  outward  direction  almost  in  the  axis 
of  the  arm.  The  aneurism  needle  should  be  passed  from  above  down- 
ward, because  there  is  more  danger  of  encircling  the  nearest  cord  of  the 
brachial  plexus  than  of  injuring  the  vein  which  lies  at  some  distance  from 
the  artery,  though  below  it.     This  is  an  exception  to  the  axiom  which 


COMilOX    CAROTID    ARTERY.  293 

directs  the  needle  to  be  passed,  as  a  rule,  first  between  the  vein  and  the 
artery  about  to  be  ligated. 

The  chief  errors  to  be  avoided  in  the  operation  are  injury  to  the  veins 
and  ligature  of  that  portion  of  the  brachial  plexus.  During  the  dissection 
the  suprascapular  artery  or  the  transverse  artery  of  the  neck  may  be 
divided  and  require  ligation. 

Common  Carotid  Artery. — The  direction  of  the  common  carotid 
and  its  continuation,  the  internal  carotid  arterj^,  corresponds  with  a  line 
drawn  from  the  sterno-clavicular  joint  to  the  tragus  of  the  ear.  The  com- 
mon carotid  artery  extends  only  to  the  level  of  the  top  of  the  larynx, 
where  it  bifurcates  into  the  external  and  internal  carotid  arteries.  The 
left  carotid  has  its  origin  lower  than  the  sterno-clavicular  articulation,  but 
in  this  intrathoracal  portion  of  the  artery  surgeons  have  little  interest. 
This  circumstance,  however,  renders  ligation  of  the  carotid  below  the  omo- 
hyoid muscle  safer  on  the  left  than  on  the  right  side ;  because  the  ligature 
is  further  from  the  blood  stream  in  the  parent  vessel.  The  external 
carotid  at  its  origin  lies  from  a  quarter  to  a  half  inch  nearer  the  middle 
line  of  the  neck  than  the  line  given  for  the  internal  carotid. 

The  common  carotid  artei'v  lies  beneath  the  anterior  edge  of  the  sterno- 
mastoid  muscle  in  a  sheath,  which  also  encloses  the  internal  jugular  vein 
and  the  pneumogastric  nerve.  The  vein  lies  on  the  outer  side  of  the 
artery,  the  nerve  lies  behind  both  and  in  the  groove  between  them.  The 
descending  branch  of  the  hypoglossal  nerve  forms  a  loop  with  branches 
from  the  cervical  plexus  usually  upon  the  front  of,  but  sometimes  within, 
the  sheath.  The  artery  becomes  more  and  more  superficial  as  it  ascends. 
Its  sheath  is  crossed  by  the  omo-hyoid  muscle  about  midway  between  the 
sterno-clavicular  joint  and  the  top  of  the  larynx;  or,  in  other  words,  at 
the  level  of  the  cricoid  cartilage. 

For  ligation  of  the  common  carotid  the  patient's  head  should  be  thrown 
well  back,  with  the  chin  turned  toward  the  opposite  side.  A  small  pillow  or 
roll  of  cloth  under  the  nape  of  the  neck  enables  the  surgeon  to  keep  the 
patient  in  this  posture.  An  incision  of  two  and  a  half  or  three  inches 
with  its  centre  corresponding  to  the  level  of  the  cricoid  cartilage  should 
be  made  along  the  anterior  edge  of  the  sterno-mastoid  muscle.  When  the 
fascia  and  the  platysma-myoid  muscles  have  been  divided  and  the  fibres 
of  the  sterno-mastoid  become  visible  by  the  dissection,  the  margin  of  the 
latter  muscle  must  be  turned  outward  and  the  angle  between  it  and  the 
omo-hyoid  muscle,  with  its  obliquely  ascending  fibres,  found.  If  the  omo- 
hyoid is  pulled  inward  and  the  sterno-mastoid  outward,  the  sheath  of  the 
artery,  with  very  possibly  the  descending  branch  of  the  hypoglossal  nerve 
upon  it,  will  be  seen.  The  sheath  will  also  be  recognized  by  its  slipping 
sideways  betAveen  the  finger  and  the  vertebrae  behind,  and  by  the  pulsating 
vessel  within  it.  The  external  and  anterior  jugular  veins  should  be  drawn 
aside,  if  in  the  line  of  the  dissection.  When  this  cannot  be  done,  they  may 
be  tied  and  divided.  The  sheath  is  then  opened  toward  the  tracheal  side 
of  the  artery,  which  is  isolated  with  care,  and  the  needle  passed  from  with- 
out inward,  in  order  to  avoid  injury  to  the  internal  jugular  vein  lying  on 
the  outer  side  of  the  artery.  This  operation  ties  the  common  carotid 
artery  just  above  the  omo-hyoid  muscle,  which  is  the  better  situation  for 
application  of  a  ligature. 

To  Hgate  below  the  omo-hyoid,  make  a  three-inch  long  incision  just  in 
front  of  the  anterior  margin  of  the  lower  third  of  the  sterno-mastoid 
muscle.  Detach  the  inner  portion  of  the  muscle  from  the  clavicle  and 
turn  it  outward.     The  omo-hyoid  and  the  sterno-hyoid  muscles  will  thus 


294 


DISEASES    OF    THE     ARTERIES. 


be  exposed.  These  are  to  be  pulled  apart  by  hooks,  when  between  and 
below  them  will  be  seen  bulging  upward  the  sterno-thvroid  muscle.  The 
finger  thrust  down  between  the  lower  part  of  the  onio-hyoid  and  the  sterno- 
thvroid,  whii'h  is  on  a  lower  plane,  will  feel  the  artery  beating  in  its 
sheath. 


Fig.  120. 


j'lnf-'"  border  cf  Sfer^ia 
Mustcid  ^Iiisci^ 


Ligation  of  the  common  carotid  artery.     (Bryant.) 


^'  It  may  be  necessary  to  incise  the  sterno-thvroid  in  order  to  expose  fully 
the  sheath,  which  is  then  opened  and  the  aneurism  needle  pa.'^sed  around 
the  artery  from  without  inward.  In  both  operations  the  branch  of  the 
hypoglossal  nerve  should  be  protected  from  injury  as  much  as  possible. 

Internal  and  Extern.a.l  Carotid  Arteries. — The  common  caro- 
tid artery  should  not  be  tied  for  a  lesion  of  the  external  carotid  or  its 
branches  when  there  is  room  between  the  bifurcation  of  the  common 
trunk  and  the  lesion  to  allow  the  safe  application  of  a  ligature  to  the 
external  carotid.  Ligation  of  the  internal  carotid  should  be  performed 
in  many  conditions  which  formerly  have  been  treated  by  tying  the  com- 
mon carotid  trunk.' 

For  ligating  the  internal  carotid  an  incision  two  and  a  half  inches  long 
with  its  centre  about  half  an  inch  above  the  upper  border  of  the  larynx, 
should  be  made  a  little  oblique  to  a  line  drawn  from  the  sterno-clavicular 
joint  to  the  tragus  of  the  ear.  The  vessel  will  be  found  along  the  edge  of 
the  sterno-mastoid  muscle.  The  hypoglossal  nerve  crosses  the  vessel  about 
an  inch  above  its  origin,  and  the  descending  branch  of  the  same  nerve 
will  probably  be  found  running  down  the  artery.     The  hypoglossal  nerve 

'  See  Dr.  John  A.  Wyeth's  Prize  Essay  on  this  subject.  Trans.  American  Med.  Asso- 
ciation, 1878. 


POSTERIOR    TIBIAL    ARTERY.  295 

and  the  digastric  muscle,  which  also  crosses  the  artery,  should  be  drawn 
upward  and  the  ligature  passed  from  without  inward,  avoiding  constric- 
tion of  the  internal  jugular  vein  and  thepneumogastric  nerve  on  the  outer 
side,  the  external  carotid  on  the  inner  side  and  the  hypoglossal  nerve 
superficially. 

The  external  carotid,  which  also  is  crossed  by  the  hypoglossal  nerve 
and  digastric  muscle,  may  be  tied  by  a  similar  incision,  but  it  must  be 
remembered  that  this  artery  is  placed  a  little  nearer  the  middle  line  of 
the  neck  than  the  internal  carotid. 

If  a  large  branch  is  given  oif  near  the  point  of  ligation,  it  also  should 
be  tied. 

Anterior  Tibial  Artery. — A  line  drawn  dow-n  the  front  of  the 
leg  from  the  inner  side  of  the  head  of  the  fibula  to  a  point  midway  be- 
tween the  two  malleolar  prominences  marks  the  direction  of  the  anterior 
tibial  artery.  The  vessel,  throughout  its  course,  lies  along  the  outer 
margin  of  the  anterior  tibial  muscle.  It  is  deeply  placed  upon  the  front 
of  the  interosseous  membrane,  at  its  upper  part ;  but  it  gradually  becomes 
superficial  as  it  descends  to  the  ankle,  where  it  is  found  immediately  under 
the  deep  fascia.  It  can  be  quite  readily  tied  in  its  middle  third  by  an 
incision,  three  inches  long,  made  a  little  obliquely  to  the  line  given  above. 
The  operator,  before  incising  the  deep  fascia,  can  usually  define  the  inter- 
muscular space  bounding  the  outer  border  of  the  anterior  tibial  muscle, 
by  a  yellowish-white  line  of  fat  showing  through  the  deep  fascia.  The 
deep  fascia  should  be  divided  just  as  the 
skin  and  superficial  fascia  have  been  ;  after 
which  the  space  between  the  anterior  tibial 
muscle  and  the  long  extensor  of  the  toes 
should  be  torn  open  with  the  finger  or  end 
of  the  grooved  director.  This  procedure 
will  expose  a  third  muscle,  the  extensor  of 
the  great  toe,  lying  between  ihe  two  just 
mentioned  and  at  a  lower  level.  Search  in  the 
bottom  of  the  fissure  between  this  extensor 
of  the  great  toe  and  the  anterior  tibial 
muscle  will  reveal  the  artery,  with  the  an- 
terior tibial  nerve  lying  to  the  outer  side  or 
a  little  in  front.  It  is  possible  that  the  ex- 
tensor of  the  great  toe  may  have  its  origin  Ligation  of  anterior  tibial  artery. 
fiom  the  fibula  lower  than  usual,  then  the  (Smith.) 

vessel  will  be  found  in  the   same  manner, 
but  between  the  anterior  tibial  muscle  and  the  long  extensor  of  the  toes. 

The  operator  must  remember  to  keep  close  to  the  outer  margin  of  the 
anterior  tibial  muscle.  If  he  mistakes  the  proper  intermuscular  space  he 
will  fail  to  reach  the  vessel.  Passive  motion  of  the  great  toe,  of  the 
smaller  toes,  and  of  the  ankle  joint  will  enable  him  to  distinguish  the 
various  muscular  bellies  in  the  wound. 

Posterior  Tibial  Artery. — The  course  of  this  artery  is  indicated 
by  a  line  drawn  from  the  middle  of  the  popliteal  space  to  a  point  midway 
between  the  tip  of  the  inner  malleolus  and  the  anterior  border  of  the 
tendon  of  Achilles.  The  vessel,  w'hen  it  gets  behind  the  inner  malleolus 
curves  forward  and  goes  to  the  sole  of  the  foot.  Behind  the  malleolus  it 
is  covered  only  by  the  skin  and  the  superficial  and  deep  fascias.  The 
deep  fascia  is  very  thick  because  of  fibres  prolonged  from  the  lateral  liga- 
ment of  the  ankle-joint.     Ligation  of  the  artery  at  this  point  is  readily 


296 


DISEASES    OF    THE    ARTERIES. 


eftected  by  a  crescentic  incision  of  two  inches  in  length,  situated  half  an 
inch  behind  the  malleolus,  with  its  concavity  toward  that  bony  projec- 
tion. A  single  large  nerve,  the  posterior  tibial,  is  usually  found  on  the 
posterior  or  heel  side  of  the  artery  ;  sometimes  tiiere  are  two  small  nerves, 
one  on  each  side.  The  tendons  of  the  posterior  tibial  muscle  and  long 
flexor  of  the  toes  lie  in  front  of  the  artery — that  is,  nearer  the  malle- 
olus; the  tendon  of  the  long  flexor  of  the  great  toe  behind  it  and  deej>er. 
Occasionally  the  artery  bifurcates  into  the  two  plantar  arteries  before 
reaching  the  sole;  in  such  a  case  the  two  vessels  may  be  tied. 


Fig.  122. 


Ligation  of  posterior  tibial  artery.     (Bryant.) 

In  the  middle  of  the  leg  the  posterio-tibial  artery  lies  beneath  the  gas- 
trocnemius and  soleus  muscles  and  upon  the  posterior  tibial  muscle  and 
the  long  flexor  of  the  toes.  It  is  separated  from  the  soleus  by  a  septum 
of  the  deep  fascia  and  has  the  posterior  tibial  nerve  lying  on  the  outer  or 
fibula  side.  The  artery  can  be  ligated  from  the  side  of  the  calf  as  fol- 
lows: Lay  the  leg  on  its  outer  aspect  with  the  knee  flexed  and  the  heel 
raised  to  relax  the  calf  muscles.  Make  an  incision  of  four  or  five  inches, 
parallel  to  and  half  an  inch  behind  the  inner  margin  of  the  tibia.  If  the 
gastrocnemius  is  seen,  draw  it  away  from  the  tibia  and  expose  the  soleus ; 
if  it  is  not  seen,  the  soleus  will  be  exposed  at  once.  The  soleus  is  then 
to  be  cut  from  its  attachment  to  the  tibia  by  carrying  the  knife,  with  its 
edge  directed  against  the  bone,  along  the  entire  length  of  the  cutaneous 
incision.  By  drawing  the  cut  muscle  outward  the  surgeon  will  uncover 
the  septum  of  deep  fascia  that  lies  over  the  artery.  The  vessel  can  be 
seen  or  felt  beneath  this  fascia  about  an  inch  from  the  edge  of  the  tibia 
and  is  readily  uncovered  by  incising  the  fascia,  which  may  be  thick,  with 
the  knife. 

The  operator  may  mistake  the  gastrocnemius  for  the  soleus  because  the 
incision  was  made  too  far  from  the  tibia,  or  he  may  cut  too  close  to  the 
tibia  and,  therefore,  fail  to  recognize  the  soleus  and,  as  a  result  separate 
not  only  it  but  the  deeper  muscles  fi'om  the  tibia  and  get  down  to  the 
interosseous  membrane. 

The  knife  should  be  held  with  its  edge  toward  the  bone  in  order  not  to 
make  an  oblique  section  of  the  soleus.  There  is  an  intramuscular  septum 
in  the  middle  of  the  soleus  which  is  parallel  to  the  septum  of  deep  fascia 
under  which  the  artery  lies.     This  may  mislead  the  surgeon,  who  will 


EXTERNAL    AND    COMMON    ILIAC    ARTERIES. 


297 


think  he  has  cut  entirely  through  the  muscle  when  he  has  only  gone  half- 


Ligation  of  femoral  artery.     (Smith). 


way. 

Femoral  Artery. — The  common  femoral  artery  and  the  upper  part 
of  its  continuation,  the  superficial  femoral,  have  their  course  indicated  by 
a  line  drawn  from  a  point  mid- 
way between  the  anterior  superior  Fig.  123. 
spine  of  the  ilium  and  the  sym- 
physis of  the  pubes,  where  the 
pulsation  can  always  be  felt,  to 
the  prominence  of  the  internal 
condyle  of  the  femur.  This  line 
bisects  Scarpa's  triangle,  running 
from  the  centre  of  the  base 
through  its  apex.  Scarpa's  tri- 
angle is  bounded  by  Poupart's 
ligament  above,  the  sartorius 
muscle  externally,  and  the  long 
adductor  muscle  internally.  The 
apex  of  the  triangle  at  the  point 
of  junction  of  these  muscles  is  on 
the  inner  side  of  the  thigh.  The  vein  corresponding  with  the  arteries 
lies  upon  their  inner  side  except  near  the  apex  of  Scarpa's  triangle,  where 
it  passes  behind  the  artery,  and  finally  gets  to  the  outer  side.  The  ante- 
rior crural  nerve  is  on  the  outside  of  the  arteries,  and  at  a  distance, 
except  near  the  apex  of  the  triangle,  where  one  of  its  branches  lies  close 
to  the  vessel.  It  is  well  to  remember  that  in  fat  persons  the  fold  of  the 
groin  is  a  little  below  Poupart's  ligament,  and  does  not,  as  in  lean 
patients,  correspond  with  the  ligaments. 

The  superficial  femoral  artery  is  to  be  ligated  where  it  is  crossed  by 
the  sartorius  muscle  at  the  apex  of  Scarpa's  triangle,  which  is  about  four 
inches  below  Poupart's  ligament.  The  thigh  should  be  everted  and  an 
incision  three  or  four  inches  long  made  at  this  point,  a  little  oblique  to 
the  line  of  the  artery,  avoiding  the  internal  saphenous  vein.  When  the 
inner  border  of  the  sartorius  is  recognized  by  its  fibres  passing  obliquely 
downward  and  inward,  the  proper  landmark  or  guide  has  been  found. 
The  edge  of  this  muscle  should  be  turned  up  and  under  it  will  be  discov- 
ered the  sheath  of  the  artery,  running  in  the  direction  indicated  by  the 
line  already  mentioned.  The  vein  will  probably  be  a  little  behind  the 
artery,  though  on  its  inner  side.  The  ligature  should  be  passed  from 
within  outward.  The  artery  is  so  superficial  that  its  pulsation  can  usually 
be  felt  through  the  tissues  before  the  first  incision  is  made. 

The  common  femoral  artery  is  readily  secured  by  making  an  incision 
two  inches  long  parallel  to  Poupart's  ligament,  and  a  half  inch  below  its 
centre.  Some  lymphatic  glands  may  require  pushing  aside  when  the 
superficial  fascia  is  being  divided  ;  after  which  incision  of  the  deep  fascia 
will  disclose  the  sheath  of  the  artery.  The  vein  is  on  the  inner  side  of 
the  artery,  hence  the  ligature  should  be  carried  around  from  the  inner  side. 

External  and  Common  Iliac  Arteries. — The  course  of  the  com- 
mon iliac  artery  and  its  direct  continuation,  the  external  iliac,  is  indicated 
by  a  line  drawn  from  the  left  side  of  the  umbilicus,  on  a  level  with  the 
top  of  the  iliac  crest,  to  a  point  midway  between  the  anterior  superior 
spine  of  the  ilium  and  the  symphysis  of  the  pubes.  The  upper  third  of 
this  line  corresponds  with  the  common,  the  lower  two-thirds  with  the 
external  iliac ;  though  this  proportion  often  varies,  because  the  bifurca- 


298 


DISEASES    OF    THE    ARTERIES. 


tioii  of  the  coiniiion  trunk  into  external  and  internal  iliac  varies  in 
location. 

The  common  iliac  has  the  peritoneum  just  in  front  of  it  and  is  crossed 
at  its  lower  end,  near  the  point  of  bifurcation,  by  the  ureter.  The  rectum 
as  it  descends  into  the  pelvis  also  crosses  the  left  artery.  The  lower  part 
of  the  common  and  the  entire  length  of  tlie  external  iliac  lie  along  the 
inner  border  of  the  great  psoas  muscle.  The  common  iliac  vein  on  the 
left  side  of  the  body  lies  at  the  inner  side  of  the  artery  ;  on  the  right 
side  it  is  behind  the  artery  at  its  lower  part,  and  on  the  other  side  above. 
This  may  be  memorized  by  the  fact  that  each  common  iliac  vein  lies  ou 
the  right  side  of  the  corresponding  artery. 

The  external  iliac  arteries  are  covered  by  the  peritoneum,  and  have  the 
veins  lying  internally  and  the  genital  branch  of  the  genito-crural  nerve 
lying  externally.  Near  Poupart's  ligament  the  external  iliac  is  crossed 
by  the  vas  deferens  and  the  spermatic  vessels,  and  gives  off  two  branches. 
It  must  not  be  tied  here. 

The  external  iliac  artery  is  reached  for  ligation  by  a  crescentic  inci- 
sion of  four  or  five  inches  in  length,  with  its  convexity  downward,  begin- 
ning an  inch  ab  )ve  and  an  inch  outside  of  the  middle  of  Poupart's 
ligament,  and  ending  at  a  point  an  inch  above  the  anterior  superior  iliac 
spine.  This  will  probably  cut  the  superficial  epigastric  artery,  which  will 
require  tying.  The  tendon  of  the  external  oblique  muscle,  which  is  ex- 
posed, must  be  divided  to  the  same  extent  as  the  skin,  either  with  the 
knife's  edge  held  perpendicular  to  its  surface,  or  upon  a  director. 

Fig.  124. 


Lines  of  incision  for  (A)  common  iliac,  (B)  external  iliac,  (C)  femoral  arteries. 

(Stimson.) 


The  fibres  of  the  internal  oblique  and  transversalis  muscles  must  be 
divided  in  the  same  way.  If  it  is  preferred,  the  last  may  be  divided  on 
a  grooved  director.  The  transverse  fascia  is  now  exposed.  It  may  be 
thick  and  white  or  thin  and  transparent.     It  should  be  carefully  torn 


EXTERNAL    AND    COMMON    ILIAC    ARTERIES. 


299 


througli  with  the  forceps  and  fingers,  when  the  bluish,  though  rough 
looking,  outer  surface  of  the  peritoneum  will  be  seen  crossing  the  bowels. 
The  operator  Avith  his  finger  loosens  this  serous  membrane  from  the 
front  of  the  iliac  fossa  and  vessels ;  beginning  at  the  external  end  of  the 
wound,  where  the  attachment  is  least  strong. 


Fig.  125. 


Pcriicneum 
S/icr?naltc  Card, 


Oeefi  fascia         li, 

Saricriios  inusrlc     ~^~ 


■Itene/r.  Sa/i/ien  a 
nerve 


Ligation  of  external  iliac  and  femoral  arteries.    (Bryant. 


The  assistant,  who,  during  the  incision  was  pressing  on  the  belly  wall 
to  make  the  muscles  tense,  now  puts  a  broad  spatula  into  the  wound  and 
draws  the  peritoneum  inward. 

The  artery  and  vein  in  a  sheath  of  fascia  will  now  be  felt  along  the 
inner  border  of  the  belly  of  the  psoas.  After  the  sheath  has  been 
opened,  the  aneurism  needle  is  carried  around  from  within  outward. 

The  incision  given  should  be  carefully  followed  as  to  length  and  curve 
through  its  entire  depth.  It  should  not  go  nearer  the  middle  line  lest  it 
cut  into  the  external  abdominal  ring,  nor  lower,  lest  it  open  the  inguinal 
canal  or  cut  the  deep  circumflex  iliac  artery.  When  the  director  is  pushed 
under  the  tissues  it  should  be  kept  longitudinal,  so  as  not  to  puncture 
deeper  layers  unawares.  It  is  wise  not  to  incise  all  the  way  to  its  end, 
lest  the  peritoneum  be  folded  over  the  extremity  and  thereby  be  wounded. 


300 


DISEASES    OF    THE    ARTERIES. 


The  commou  iliac  artery  can  be  reached  by  an  incision  similar  to  that 
used  for  the  external  iliac,  but  beginning  an  inch  higher  and  extending 
about  two  inches  further  upward  toward  the  last  rib.  The  muscles  and 
transversalis  fascia  are  divided  in  the  same  manner  a^  just  described. 
Wlien  the  peritoneum  i?;  pushed  inward  the  ureter  and  spermatic  vessels 
are  carried  with  it,  as  they  adhere  to  its  outer  surface.  The  artery  can 
then  be  felt  near  the  promontory  of  the  sacrum.  The  needle  should  be 
carried  from  right  to  left  on  each  side  of  the  body,  as  the  vein  lies  to  the 
right  of  the  artery  in  each  instance. 

The  ureter  might  be  tied  instead  of  the  artery  if  the  operator  is  not 
careful,  and  in  case  of  high  bifurcation  of  the  common  iliac  the  ligature 
might  in  error  be  applied  to  the  external  iliac  artery. 

Internal  Iliac  Artery. — This  vessel  extends  from  the  bifurcation 
of  the  common  iliac  at  the  sacro-iliac  junction  to  the  top  of  the  great 
sacro-sciatic  foramen  with  the  ureter  and  peritoneum  in  front,  its  vein 
and  the  sacral  plexus  of  nerves  behind.  It  is  ligated  by  an  incision  sim- 
ilar to  that  for  tying  the  common  iliac. 

These  methods  of  reaching  the  common  and  internal  iliac  arteries  are 
somewhat  complicated  and  difficult  because  of  the  great  depth  of  the 
wound.  It  is  a  question  whether  a  laparotomy  in  one  of  the  semilunar 
lines  with  ligation  of  the  vessel  through  the  peritoneum  is  not  simpler, 
and  therefore  easier  and  safer. 


Arterial  Yarix  or  Varicose  Arteries. 


Artex'ies  may   become  dilated   and  elongated,  presenting   a  condition 
similar  to  varicose  veins.     The  term  arterial  varix   is  generally  applied 

to  such  a  pathological  change  if  the 
Fig.  120.  artery  atlected  be  a  large  vessel,  such 

as  the  temporal,  facial,  or  iliac,  while 
to  similar  dilatation  of  the  terminal 
subcutaneous  arterioles  of  a  normal 
diameter  of  about  one-fiftieth  of  an 
inch  the  term  cirsoid  aneurism  has 
been  applied.  I  shall  discard  the 
latter  name,  since  the  condition 
has  no  pathological  resemblance  to 
aneurism,  and  use  the  term  arterial 
varix,  or  varicose  artery,  for  dilata- 
tion and  elongation  of  prei'.ristinr/  ar- 
teries of  any  size,  provided  their  pre- 
existence  can  be  demonstrated  clinic- 
ally or  microscopically.  When  there 
is  a  development  of  new  vessels  with 
arterial  characteristics,  it  is  proper 
to  call  the  mass  or  tumor  an  arterial 
angeioma.  It  may  at  times  be  diffi- 
cult to  determine  clinically  whether 
the  pulsating  growth  is  composed 
principally  of  new  veasels  or  preex- 
isting ones. 

A  varicose  artery  in  addition  to  being  generally  dilated,  may  show 
irregular  pouches  or  sacculations.     The  middle  tunic  especially  is  thinned 


Arterial  varix  of  the  [i.tlni  and  fingers. 
(Agxew.) 


ARTERIAL    TARIX    OR     VARICOSE    ARTERIES.  301 

uutil  the  artery  looks  like  a  vein  ;  hence  the  blood  current  may  become 
very  sluggish.  The  cause  of  the  change  is  probably  some  obscure  vaso- 
motor disturbance  leading  to  loss  of  muscular  tone  in  the  middle  coat. 
Atheroma  seems  not  to  be  a  factor  in  the  causation. 

Arterial  varix  is  exhibited  as  a  pulsating  tumor  with  an  irregular, 
nodulated  surface,  which  usually  shows  the  position  beneath  the  skin  of 
the  dilated  arteries.  When  the  hand  is  applied  to  the  tumor  a  vi- 
bratoiy  thrill  is  felt  that  in  some  cases  resembles  the  wriggling  of  a 
mass  of  worms.  Pulsation  may  be  distinct  and  is  more  general  than 
the  limited  pulsation  felt  in  aneurismal  varix  or  arterio-v'enous  fistula 
between  vein  and  artery.  Auscultation  reveals  a  blowing  or  cooino- 
murmur.  Pressure  upon  the  aiferent  artery  stops  all  movement  and 
murmur.  If  there  are  several  arteries,  pressure  on  one  merelv  dimin- 
ishes these  signs.  When  the  disease  affects  a  number  of  small  arterioles 
the  tumor  has  a  spongy  feel,  and  the  outline  of  the  vessels  is  not  traceable 
through  the  skin.  If  an  arterial  varix  shows  no  tendencv  to  increase  in 
bulk,  and  is  not  threatening  hemorrhage  from  inflammatory  and  ulcera- 
tive processes,  it  should  be  let  alone.  If  treatment  is  demanded,  excision 
or  ligation  should  be  done  in  the  manner  described  in  the  section  which 
discusses  angeiomas.  This  is  better,  and  probably  safer,  than  injection 
with  coagulating  fluids. 


C  H  A  P  T  E  K    X  V  1  I. 

DISEASES   AND  INJURIES  OF   BONES. 


PERIOSTITIS. 

Causes. — Periostitis,  or  inflammation  of  the  tibrous  membrane  cover- 
ing the  exterior  of  bones,  is  caused  by  injuries,  such  as  contusions,  and  by 
certain  constitutional  conditions,  such  as  rheumatism,  gout,  and  especially 
syphilis.  Agnew  believes  that  it  may  be  due  to  violent  traction  of  muscles 
inserted  into  the  periosteum.  The  vessels  of  the  periosteum,  of  the  bone, 
and  of  the  medulla  are  continuous  through  the  ramifications  of  Haver- 
sian canals  and  sj)aces.  Hence,  inflammation  of  one  of  these  structures 
is  usually  associated  with  inflammation  of  the  other  in  the  same  locality. 
As  ostitis  is  really  an  inflammation  of  the  medulla  within  the  bone  spaces, 
it  may  be  the  cause  of  periostitis,  and  periostitis  may  similarly  be  the 
cause  of  ostitis  or  of  myelitis. 

PATHOLOCiY. — The  pathological  changes  seen  in  periostitis  are  conges- 
tion, thickening,  and  softening  of  the  membrane  due  to  rapid  cell-prolifera- 
tion and  accumulation  of  the  wandering  blood  cells.  The  deepest  layer 
of  the  membrane,  which  is  that  which  causes  bone  growth,  is  especially 
active  in  cell  formation  ;  hence,  the  membrane  is  raised  from  the  bone  by 
a  subjacent  exudate  and  becomes  easily  detachable.  The  l)one  imme- 
diately beneath  the  inflamed  area  also  becomes  inflamed  and  softened  to 
a  limited  extent.  If  resolution  occurs,  this  exudate  is  absorbed,  and  the 
elevation,  or  node,  caused  by  the  cells  and  fluid  lieneatli  the  periosteum 
disappears.  At  other  times,  the  inflammation  does  not  subside  so  easily  ; 
this  new  material  becomes  organized  into  bone,  and  there  is  left  a  per- 
manent change  in  the  contour  of  the  skeleton.  The  entire  bone  may  be 
enlarged  if  the  periostitis  is  wide-spread.  Flattened  bony  elevations  or 
nodes  are  of  frequent  occurrence  after  syphilitic  periostitis,  and  often  aid 
in  establishing  the  constitutional  causation  of  later  obscure  lesions  in 
other  parts  and  tissues.  In  periostitis,  if  pyogenic  bacteria  be  present, 
suppuration  may  take  place  between  the  membrane  and  bone,  giving  rise 
to  subperiosteal  abscess,  also  called  cortical  osteomyelitis,  and  secondarily 
causing  superficial  necrosis  of  the  bone  in  the  vicinity.  Periostitis  of 
syphilitic  origin  occurring  in  the  later  stages  of  this  constitutional  disease 
is  more  prone  to  suppuration  than  when  it  occurs  earlier.  In  diffuse  sup- 
purative periostitis  the  membrane  is  separated  from  a  large  surface  of 
bone,  and  the  vessels  going  to  the  bone  are  injured  and  stretched  and  be- 
come the  seat  of  thrombosis.  The  surface  of  the  bone,  therefore,  becomes 
necrotic.  If  there  is  concurrent  suppurative  inflammation  of  the  marrow 
in  the  medullary  canal,  which  is  not  infrequently  the  case,  the  necrosis 
will  involve  the  entire  thickness  of  the  bone  and  not  merely  the  outer 
surface.  Death  from  pyseraia  may  occur  in  such  c(mditions.  Subperi- 
osteal hemorrhages  are  sometimes  found.  This  bleeding  may  be  mechanical 
and  due  to  forcible  and  rapid  dissection  of  the  membrane  from  the  bone 
by  the  sudden  inflammatory  exudation.     Acute  infective  perio.stitis  is  a 


PEKIOSTITIS.  303 

variety  of  suppurative  periostitis  and  is  liable  to  be  followed  by  septi- 
csemia  or  pyaemia.  It  is  usually  associated  with  acute  infective  osteo- 
myelitis, and  is,  of  course,  due  to  bacteria,  probably  the  bacteria  of  or- 
dinary suppuration. 

Symptoms. — The  symptoms  of  circumscribed  periostitis,  which  is  by 
far  the  most  common  form,  are  pain,  often  worse  at  night,  tenderness  on 
pressure,  heat  of  the  surface,  circumscribed  swelling  and,  perhaps,  local 
oedema.  Persons  whose  occupations  require  them  to  work  at  night  and 
sleep  in  daytime  may  have  more  pain  during  the  day  than  at  night.  The 
deposition  beneath  the  membrane  may  cause  the  parts  to  feel  baggy  or 
puffy  on  strong  pressure  with  the  fingers.  The  swelling  has  not  abrupt 
edges,  but  gradually  reaches  the  level  of  the  surrounding  surface.  The 
pain  is  often  excruciatingly  severe  and  of  a  throbbing  character.  Red- 
ness of  the  surface  occurs  late  and  sometimes  at  no  time  during  the  pro- 
gress of  the  inflammation.  The  tibia,  clavicle,  ulna,  and  cranial  bones 
are  very  frequently  the  subjects  of  syphilitic  periostitis.  Diffuse  perios- 
titis, which  is  probably  usually  infective,  is  very  rapid  in  its  course,  while 
the  circumscribed  variety  is  often  a  disease  of  slow  development  and 
progress.  The  former  attacks  JDarticularly  the  long  bones  of  tuberculous 
persons  in  early  life,  and  is  accompanied  by  violent  constitutional  dis- 
turbance. In  this  violent  periosteal  lesion  chills,  high  fever,  and  delirium 
occur,  and  are  accompanied  by  rapidly-spreading  inflammation  of  the 
limb,  which  is  shown  by  great  pain,  swelling,  cedema,  and  enlarged  veins 
from  obstruction  to  deep  circulation.  Ostitis,  endositis,  epiphysitis,  and 
even  arthritis  often  follow  in  its  train.  Death  from  septicaemia  or  pyaemia 
is  not  uncommon.  Diffuse  suppurative  periostitis  of  the  digital  phalanges 
is  often  called  whitlow  or  felon. 

The  diagnosis  of  circumscribed  periostitis  is  easy.  It  is  usually  syphil- 
itic when  not  traumatic.  The  diffuse  or  suppurative  form  may  be  mis- 
taken for  diffuse  cellulitis,  but,  as  a  rule,  it  does  not  extend  beyond  the 
joints  at  the  extremities  of  the  bone  affected.  Suppurative  cellulitis  fre- 
quently passes  beyond  joints.  From  rheumatism,  periostitis  is  dis- 
criminated by  the  swelling,  which  is  not  apt  to  be  situated  at  the  joints, 
and  by  the  evidences  of  suppuration  in  the  purulent  form  of  periostitis. 
Acute  infective  periostitis  is  often  mistaken  for  rheumatism,  and  must  be 
remembered  as  a  possibility  when  such  violent  general  symptoms,  in 
young  persons,  are  associated  with  pain  about  the  tibia  and  femur. 

Treatment. — The  treatment  of  acute  periostitis  of  a  sthenic  type 
should  consist  of  cathartics  and  diaphoretics  combined  with  anodynes. 
The  asthenic  cases  demand  iron,  qumine,  and  stimulants  with  concen- 
trated food  and  anodynes.  Locally,  leeches,  lead  water  and  laudanum, 
and  moist  antiseptic  dressings  should  be  employed  in  the  acute  form  ; 
tincture  of  iodine  and  blisters  in  the  more  chronic  cases. 

As  syphilis  is  probably  the  commonest  cause  of  non-traumatic  periostitis 
full  doses  of  iodide  of  potassium  should  be  administered.  The  dose 
should  not  be  less  than  10  grains  three  times  a  day  after  meals,  and  may 
be  increased  to  30  or  40  grains  in  a  rebellious  case.  As  this  lesion  is  a 
manifestation  of  the  later  stages  of  syphilis,  the  iodides  are  possibly  more 
efficacious  than  mercury.  The  two  remedies  may  be  combined.  The 
pain  of  syphilitic  periostitis,  often  called  syphilitic  neuralgia,  can  fre- 
quently be  promptly  cured  by  these  large  doses  of  potassium  iodide. 
When  the  pain  of  periostitis  of  any  origin  does  not  promptly  subside, 
free  incision  of  the  tense  fibrous  periosteum  is  the  proper  surgical  remedy. 
The  tension  due  to  the  subperiosteal  exudation  is  thus  removed,  and  as  a 


304  DISEASES    AND    INJIFRIES    OF    BONES. 

consequence  pain  is  relieved,  resolution  favored,  and  the  danger  of  sec- 
ondary necrosis  lessened.  In  nonsuppurative  ca.-^es  the  incision  is  to  be 
done  subcutaneously  by  passing  a  tenotome  through  the  skin  in  one  or 
more  places  and  incising  the  periosteum  freely  and  deeply  in  every  direc- 
tion l)y  pushing  the  knife  as  far  under  the  tissues  as  the  handle  will  allow. 
lu  suppurative  periostitis  free  incision  must  at  once  be  made  through  the 
skin  and  other  tissues  directly  down  to  the  bone.  If  the  bone  becomes 
necrotic  notwithstanding  this  line  of  treatment,  it  should  be  removed  as 
soon  as  the  patient  can  bear  the  shock.  Some  reproduction  of  bone  may 
subsequently  take  place  from  the  shreds  of  the  periosteum  not  destroyed 
l)y  the  violent  inflammation  and  from  the  medullary  tissue  in  the  inter- 
stices of  the  living  bone.  If  great  destruction  occurs  from  involvement 
of  the  medullary  membrane  and  the  joints  amputation  may  be  demanded. 

Ostitis  or  Osteomyei-itis. 

Cau.-<E8. —  Ostitis  or  osteomyelitis  may  arise  from  contusions  of  bone, 
fractures,  amputations,  and  other  injuries,  and  from  various  constitutional 
deteriorations  and  mycotic  affections  such  as  rheumatism,  syphilis,  tuber- 
culosis, and  loAV  fevers. 

Pathology. — Inflammation  of  bone  is  pathologically  identical  with 
inflammation  of  the  sofl  tissues,  for  it  is  the  soft  or  animal  tissue  in  the 
Haversian  spaces,  canaliculi,  and  lacunse  of  the  bone  that  undergoes  the 
morbid  process.  The  earthy  constituents  cannot  inflame;  they  only  show 
the  impress  of  the  alterations  induced  in  the  vascular  and  other  living 
tissues.  When  the  inHammatiim  affects  the  soft  structures  within  the 
spaces  mentioned  the  term  ostitis  is  used;  when  the  marrow  in  the  medul- 
lary canal  is  the  seat  of  these  changes  the  term  myelitis  or  endostitis  is 
used.  As  ostitis  is  usually,  if  not  always,  associated  with  myelitis,  sur- 
geons now  use  the  word  osteomyelitis  almost  exclusively,  having  dropped 
to  a  great  extent  the  word  ostitis,  except  when  speaking  of  chronic  in- 
flammations, when  ostitis  is  still  used  to  some  extent. 

The  increased  vascularity  of  inflammation  is  followed  by  softening  of 
the  bone,  due  to  absorption  of  the  earthy  structures  and  the  filling  of  the 
vascular  canals  and  spaces  with  embryonic  cells  and  migrating  blood 
corpuscles.  The  coalescence  of  numerous  canals  and  spaces  by  the  ab- 
sorptive process  exerted  on  their  walls,  makes  the  bone  much  more  porous, 
while  the  increase  in  cellular  elements  gives  it  a  soft  and  spongy  charac- 
ter. This  process  has  been  called  "rarefying  ostitis,"  or  " dry  caries," 
because  the  bone  is  eaten  away  as  if  ulcerated,  but  without  any  pus  for- 
mation. Changes  in  shape  of  long  bones  or  vertebrte,  due  to  this  process, 
occur,  hence  the  name  "  deforming  ostitis."  This  is  the  change  that 
occurs  when  aneurisms  cause  absorption  of  the  bone,  when  sequestrie  are 
loosened,  and  when  the  ends  of  broken  bones  are  rounded  off.  The  infiam- 
matory  cellular  infiltration  or  exudate  may  be  absorbed  and  the  ostitis 
may  thus  be  terminated  by  resolution  without  leaving  jjermanent  change. 
This  is  possible  only  in  the  early  stages,  or  in  a  very  mild  degree  of  in- 
flammation. 

More  frequently  the  cells  become  converted  into  osseous  tissue,  which, 
though  formed  in  the  widened  Haversian  canals  and  medullary  spaces, 
encroaches  upon  the  calibre  of  these  channels  so  much  that  they  become 
smaller  than  they  were  originally.  Thus  the  bone  becomes  harder,  more 
compact  or  ivory-like,  and,  as  a  consequence,  heavier  than  it  was  previous 


OSTITIS    OR    OSTEOMYELITIS.  305 

to  the  occurrence  of  ostitis.  This  is  the  pathological  nature  of  most  cases  of 
chronic  ostitis.  As  enlargement  takes  place  both  in  diameter  and  length 
during  the  stage  of  softening  and  swelling  because  of  the  coincident  perios- 
titis and  epiphysitis,  an  inflamed  bone  which  is  thus  sclerosed  becomes  of 
greater  bulk  as  well  as  harder  than  it  was  -previously.  This  sclerosis  or 
"  condensing  ostitis  "  may  be  found  accompanying  "  rarefying  ostitis  "  in 
the  same  specimen. 

The  osteomyelitic  inflammation  may  terminate  in  softening  and  degen- 
eration which  will  cause  the  so-called  "  cold  "  or  "  chronic  abscess  "  of 
bone.  The  puriform  fluid  contained  in  such  cavities  is  not  true  pus.  It 
is  well  to  remember  that  such  abscesses  are  probably  always  due  to  the 
tubercle  bacillus.  When  they  occur  in  syphilitic  persons  it  is  possible 
that  the  syphilitic  taint  favors  infection  with  the  tubercle  bacillus.  Pus 
from  inflamed  bone  contains  oil  globules  in  considerable  numbers  and  is 
due  to  infection  from  pus  bacteria.  Septic  osteomyelitis  is  then  the  con- 
dition. This  last  process  is  acute.  Ulceration  of  bone,  termed  caries, 
and  mortification  of  bone,  called  necrosis,  may  follow  ostitis.  The  various 
stages  and  results  of  ostitis  may  often  be  found  in  different  j^arts  of  the 
same  bone.  When  repair  takes  place  after  deforming  ostitis,  tubercular 
ostitis  or  traumatic  ostitis  after  fractures,  the  process  is  one  of  ossification 
of  granulation  tissue  which  fills  in  the  gap.  It  is  simply  a  bony  trans- 
formation of  scar  tissue.  This  process  is  well  shown  in  some  cases  of 
curvature  of  the  spine  cured  without  the  formation  of  puriform  discharge. 

Acute  inflammation  of  the  bone  and  marrow  may  be  traumatic ;  or  it 
may  occur  without  visible  injury,  and  is  then  called  spontaneous  osteo- 
myelitis. In  the  latter  case  it  is  usually  diffuse ;  in  the  former  case  it 
may  be  diffiise,  but  frequently  is  not  so.  In  acute  diffuse  osteo-myelitis 
the  marrow  is  injected  and  swollen,  purple  or  marked  with  red,  yellow, 
and  purplish  streaks,  and  protrudes  in  a  fungous  mass  from  the  medullary 
canal  when  the  bone  is  sawed.  Oil  and  pus  escape  from  the  canal  when 
it  is  opened.  Abscesses  and  thrombosis  of  veins  are  found  in  the  tissues 
surrounding  the  diseased  bone ;  bacteria  are  found  in  the  marrow  and 
other  structures,  and  pysemic  abscesses  frequently  arise  secondarily.  It 
may  occur  in  shoi't  or  fiat  bones  as  well  as  in  long  bones,  and  is  due  to 
mycotic  infection.  The  microdrganism  or  microorganisms  are  probably 
those  known  as  pyogenic.  The  periosteum  is  often  involved  in  a  similar 
inflammation,  but  not  necessarily  so.  The  bones  are  in  severe  cases 
stripped  of  periosteum  and  become  necrotic  from  one  epiphysis  to  the 
other.  Separation  of  the  epiphysis  from  the  shaft  is  common,  and  is 
due  to  destruction  of  the  intervening  cartilage. 

Symptoms. — The  symptoms  of  ostitis  are  with  difficulty  differentiated 
from  those  of  periostitis  and  myelitis,  with  which  the  former  affection  is  so 
frequently  accompanied.  In  the  early  stages  the  symptoms  are  often  very 
indefinite.  Dull  aching  or  gnawing  pain,  especially  severe  at  night  and 
varying  with  the  conditions  of  the  weather,  is  a  common  symptom  in 
chronic  ostitis,  and  the  inflammatory  signs  spoken  of  in  the  discussion  of 
periostitis  will  probably  be  observable  in  the  later  stages. 

Enlargement  of  the  bone  without  much  change  in  its  outline  was 
formerly  thought  to  be  characteristic  of  ostitis,  but  it  is  due  largely 
to  the  concurrent  periostitis.  In  ostitis,  unaccompanied  by  much  peri- 
ostitis, irregular  flattened  swellings  on  the  surface  of  the  skeleton  change 
the  contour  greatly.  Some  of  the  increase  in  size  in  these  inflammations 
is  apparent,  being  due  to  the  overlying  soft  tissues.  A  feeling  of  weak- 
ness and  heaviness  in  the  limb  is  frequently  described  by  the  patient. 

20 


300 


DISEASES    AND    INJURIES    OF    BONES. 


Liicke  has  employed  percussion  with  a  small  nibb('r-ti|)pi'(l  haiiuuer 
to  determine  the  existence  and  exact  seat  of  osseous  intlaminations. 
Corresponding  parts  are  struck  and  the  existence  of  increased  sensibility 
determined  ;  and  then  its  superficial  or  deep  location  estimated  by  the 
force  required  to  develoj)  tenderness.  There  is  greater  dulness  on  percus- 
.<ion  when  the  bone  is  comj)act,  or  infiltrated  with  inflammatory  exudations, 
than  elsewhere. 


Malleoli  on  different  levels. 


Left  kuee  higher  than  right. 


Superficial  ulcer. 


Internal    malleolus    on    a    level 
with  external  malleolus. 


Hypertropliy  of  tibia  from  syphilitic  ostitis  (inherited). 

Acute  inflammation  of  the  bone  and  marrow,  called  acute  osteomye- 
litis, or  acute  infective  osteomyelitis,  may  be  associated  with  a  similar 
periostitis,  and  when  it  occurs  without  a  recognized  injury  is  often  mis- 
taken for  rheumatism.  The  sudden  development  of  fever  with  chills  and 
delirium,  accompanied  by  severe  pain  in  the  limb  of  a  person  so  young 
that  the  ei)iphyses  have  not  yet  become  united  to  the  shafts,  should  be 
carefully  examined  and  watched.  If  redness  and  oedema  occur,  and  espe- 
cially if  crepitation  from  inflammatory  destruction  of  the  epiphyseal 
cartilage  is  developed,  or  if  the  joint  is  involved,  the  diagnosis  of  infective 
osteomyelitis  is  confirmed.  Abscess  under  the  periosteum  and  muscles, 
necrosis,  septiciemia,  and  pyaemia  are  later  symptoms.  Thickening  of 
the  bone  and  early  ossification  of  the  epiphyseal  cartilage  will  probably 
occur  in  cases  of  only  moderate  severity.  This  disease  is  most  frequently 
found  in  the  long  bones  of  the  lower  limb ;  and  occurs  before  ossification 
of  the  epiphyseal  cartilages,  which  is  not  completed  in  the  tibia  and  femur 
until  about  the  twentieth  year. 

Treatment. — The  treatment  of  ostitis  is  almost  identical  with  that  of 
periostitis.  If  medical  remedies  fail  a  deep  periosteal  incision  should  be 
made,  which  may  be  at  once,  or  subsequently,  fi)llowed  by  longitudinal 
section  of  the  bone  with  a  Hev's  saw  or  the  circular  saw  of  the  surgical 


NECROSIS    OR    MORTIFICATION    OF    BONE.  307 

engine.  This  incision  should  be  deep  enough  to  go  into  the  cancellated 
structure  or  medullary  canal  of  the  bone.  Cutting  out  one  or  more  disks 
with  the  trephine  answers  a  similar  purpose  in  relieving  tension  and  pain, 
and  is  often  better,  even  if  there  is  no  abscess  cavity  in  the  bone  to  be 
curetted. 

Acute  infective  periostitis  and  osteomyelitis  must  be  met  by  early  and 
free  incision  of  soft  parts  and  periosteum,  down  to  the  bone,  and  thor- 
ough disinfection  of  the  diseased  tissue  with  antiseptic  solutiims.  Corro- 
sive sublimate  solution  (1 :  1000  or  1  :  2000)  is  probably  the  best ;  but  it 
must  be  watched  if  repeated  daily,  so  that  it  may  not  produce  toxic  effects. 
Beta-naphthol  solution  may  be  used  in  its  stead.  Free  drainage  and  anti- 
septic washing  of  the  cavity  daily  are  essential.  Separated  epiphyses 
should  be  kept  in  position  by  splints ;  dead  portions  of  bone  removed  and 
the  patient  kept  alive  by  tonics,  good  food,  and  stimulants  until  the  force 
of  the  mycotic  poison  has  been  exhausted.  When  the  infective  inflam- 
mation does  not  involve  the  periosteum  to  any  extent,  but  is  limited  to 
the  bone  and  marrow,  the  general  treatment  is  the  same  as  in  associated 
periostitis  and  osteomyelitis. 

The  local  treatment  consists  in  boring  into  the  bone  with  a  trephine  and 
scraping  out  with  a  curette  the  inflamed  suppurating  marrow.  If  neces- 
sary, more  than  one  trephine  opening  may  be  made,  or  two  or  more  such 
holes  may  be  connected  by  cutting  away  the  intervening  bone  with  a 
chisel.  Complete  removal  of  the  diseased  tissue  and  disinfection  of  the 
cavity  are  the  indications. 

Necrotic  bone  should  be  removed  when  it  becomes  loosened  from  the 
living  osseous  tissue.  This  is  usually  a  secondary  operation,  unless  trephin- 
ing and  curetting  have  been  done  in  the  early  stages.  The  latter  opera- 
tions are  indicated  as  soon  as  a  probable  diagnosis  is  made.  It  is  better  to 
operate  too  early  than  too  late.  Amputation  may  be  required  to  save  life 
in  infective  osteomyelitis  and  periostitis. 

Necrosis  or  Mortification  of  Bone. 

Definition. — Necrosis  is  death  of  bone  in  masses  or  in  bulk,  in  con- 
tradistinction to  caries,  which  is  death  in  minute  particles.  It  is  pathologi- 
cally identical  with  mortification  or  gangrene  of  soft  tissue. 

Causes. — Necrosis  is  caused  by  anything  that  at  once  destroys  vitality 
of  bone,  such  as  intense  heat  or  cold,  crushing  pulpefying  injuries  ;  and 
by  whatever  prevents  the  continuance  of  the  blood  circulation  through 
the  Haversian  canals  and  their  ramifications,  thereby  interfering  with  the 
bone's  nutrition.  Obstruction  of  these  blood  spaces  by  the  exudate  of 
ostitis,  and  detachment  of  the  periosteum  or  inflammation  of  the  marrow 
by  reason  of  suppurative  inflammation  of  these  structures,  are  the  most 
common  direct  causes  of  necrosis.  Osteo-myelitis,  whether  central  (endos- 
titis)  or  cortical  (periostitis)  is  probably  the  most  frequent  cause.  They 
act  by  interfering  with  proper  blood  supply,  which  is  arrested  by  stretch- 
ing, compression  and  thrombosis  of  the  vessels.  Syphilis  and  tuberculosis 
may,  by  inducing  ostitis,  act  as  remote  causes.  The  depressed  vitality  of 
old  age  and  of  eruptive  fevers,  division  or  embolism  of  the  nutrient  artery 
of  a  long  bone,  and  exposure  to  the  fumes  of  phosphorus  are  occasionally 
causes  of  mortification  of  bone.  If  a  piece  of  bone  is  torn  loose  from  its 
periosteal  attachments,  as  happens  in  compound  fractures,  necrosis  is  not 
apt  to  occur,  unless  the  wound  is  infected  with  putrefactive  or  pyogenic 


308  DISEASES    AND    INJURIES    OF    BONES. 

germ*.  Thijj  proves  that  it  is  the  septic  character  of  a  given  periostitis 
that  inclines  it  to  cause  necrosis. 

Pathology. — The  occurrence  of  necrosis  more  frequently  in  compact 
than  in  cancellated  osseous  structure  is  due  to  the  greater  ease  with  which 
the  circulation  is  obstructed  in  the  former  unyielding  structure.  The 
usually  dry  condition  of  the  dead  bone  shows  the  dependence  of  this 
necrosis  on  deprivation  of  blood  supply.  If  death  occurs  in  cancellated 
tissue,  which  is  normally  more  vascular  than  the  compact,  the  necrotic 
tissue,  especially  when  the  destruction  is  sudden,  is  moist  instead  of  dry. 

The  moist  form  of  necrosis  is  seldom  seen  except  in  military  practice, 
and  then  usually  in  the  cancellated  portions  of  bones.  It  is  liable  to 
occur  as  a  sequence  of  severe  gunshot  contusion  of  bone  or  compound 
fractures,  and  is  evidently  the  result  of  se})tic  infiectiou  of  some  sort.  The 
dead  bone  has  a  dirty-gray  or  greenish-brown  color,  is  moist  and  soft  and 
emits  a  very  offensive  odor.  The  periosteum  is  usually  found  in  a  slough- 
ing condition,  and  shows  little  tendency  to  form  new  bone.  Death  from 
pyaemia  is  a  common  result  of  moist  necrosis. 

In  the  ordinary  variety  of  necrosis  the  devitalized  bone  is  dry  and  hard, 
and  has  a  relatively  large  proportion  of  mineral  constituents.  When 
struck  with  a  probe  it  often  gives  a  sonorous  note,  but  is  not  sensitive  to 
touch,  nor  does  it  bleed.  Its  color  is  yellowish-white,  unless  it  has  become 
blackened  by  contact  with  putrid  pus  or  other  agents.  The  necrotic 
action  may  pertain  to  the  surface  of  a  bone  (superficial  necrosis)  to  a  por- 
tion some  distance  below  the,  perhaps  healthy,  bone  surface  (central 
necrosis),  or  to  the  entire  thickness  of  the  bone  (total  necrosis). 

Fig.  128. 


Central  necrosis,  showing  new  bone  and  cloaca*. 

After  osseous  tissue  has  died,  it  is  separated  from  the  living  bone  by 
the  process  of  rarefying  ostitis  or  ulceration,  exactly  as  gangrenous  parts 
are  separated  from  soft  tissues.  The  adjacent  bone  becomes  inflamed, 
softened,  and  ulcerated,  and  soon  a  line  of  demarcation  appears.  It  re- 
quires a  long  time,  varying  from  weeks  to  months,  according  to  the  extent 
and  situation  of  the  necrosis,  to  effect  complete  detachment.  Very  often 
pus  infection  occurs  and  suppuration  takes  place  between  the  dead  and 
living  bone.  During  the  accomplishment  of  this  process  the  overlying 
periosteum  becomes  abnormally  active  in  producing  bony  tissue,  probably 
because  of  the  induction  of  a  chronic  periostitis,  and  deposits  a  layer  of 
new  bone.  This  new  bone  may  form  a  covering  over  the  necrosed  part, 
or,  if  the  latter  is  central,  increase  the  thickness  of  the  surrounding  living 
bone.  In  this  manner  the  devitalized  bone  is  usually,  by  a  process  of 
invagination,  enclosed  in  a  bony  sheath  or  involucrum  of  irregular  shape, 
which,  however,  conforms  somewhat  to  the  outline  of  the  original  bone. 
If  the  periosteum  has  previously  been  entirely  destroyed,  no  invagination 
occurs.  The  dead  portion  of  bone  enclosed  in  the  sheath  is  called  the 
sequestrum,  while  the  leaf-like  portions  detached  in  cases  of  superficial 


NECROSIS    OR    MORTIFICATION    OF    BONE.  309 

necrosis  are  termed  exfoliations.  In  cases  of  total  necrosis  the  endosteum 
may  also  furnish  new  bone,  so  that  the  dead  structure  lies  between  two 
layers  of  newly-formed  osseous  tissue.  There  is  usually  no  invagination 
in  necrosis  of  the  skull  or  of  the  cancellated  bones. 

Through  the  living  bone,  whether  original  or  newly  formed,  which 
covers  the  sequestrum,  narrow  channels  or  fistules,  called  cloacae,  are  es- 
tablished by  the  discharge,  formed  at  the  line  of  demarcation,  making  its 
way  to  the  surface.  These  cloacae  communicate  with  sinuses  extending 
through  the  overlying  soft  parts  of  the  cutaneous  surface,  which  sinuses 
are  the  remains  of  collajDsed  abscesses  that  were  developed  soon  after  pus 
formed  in  the  bon^'-  structures. 

The  surfaces  of  a  sequestrum  or  exfoliation  are  usually  rough  and 
jagged,  because  the  living  bone  has  been  eaten  away  from  it  by  rarefying 
or  suppurative  ostitis.  The  external  surface  of  an  exfoliation  is  some- 
times quite  smooth,  since  it  may  have  been  originally  the  normal  surface 
of  the  bone.  The  sequestrum  may  be  dense  or  spongy,  according  as  it 
has  been  sclerosed  or  rarefied  before  death.  After  some  amputations  of 
the  thigh  in  which  the  nutrient  artery  has  been  divided,  necrosis  of  the 
area  of  bone  nourished  by  this  artery  occurs,  while  the  regions  nourished 
by  other  vessels  coming  from  the  periosteum  and  endosteum  remain 
healthy.  As  a  result,  a  tubular  or  cylindrical  sequestrum  is  formed  and 
may,  when  finally  detached,  be  pulled  out  from  the  sawn  end  of  the  bone. 

Fig.  129. 


9i    mche% 
Cylindrical  sequestrum  from  femur. 

Symptoms. — The  early  symptoms  of  necrosis  are  those  of  ostitis  fol- 
lowed by  inflammation,  and  often  of  suppuration  of  the  overlying  soft 
parts.  Through  the  openings  or  sinuses  left  after  the  evacuation  of  the 
pus,  a  hard  and  more  or  less  rough  surface  can  usually  be  felt  with  the 
probe  if  the  necrosis  is  superficial.  This  is  the  dying  or  dead  bone  un- 
covered by  periosteum.  Bare  bone,  however,  is  not  necessarily  dead  bone, 
for  after  periostitis  and  ostitis  of  a  simple  kind  we  may  have  an  ulcerated 
surface  of  bone  that  is  slow  in  healing.  In  cases  of  central  necrosis  the 
probe  must  be  passed  through  the  sinuses  in  the  soft  parts  and  the  cloacae 
in  the  involucrum  or  sheath  before  the  rough  sequestrum  can  be  felt. 
Until  sinuses  and  cloacae  have  been  formed  it  is  practically  impossible  to 
diagnosticate  necrosis  from  ostitis  or  tubercular  caries  and  abscess.  The 
fever  and  other  constitutional  symptoms  maybe  marked  during  this  early 
stage,  but  are  apt  to  decrease  in  severity  with  the  evacuation  of  any  puru- 
lent accumulation  which  may  become  thereafter  the  seat  of  putrefaction 
from  germ  infection.  From  time  to  time,  however,  exacerbations  of  the 
symptoms  may  occur,  and  new  abscesses  may  form.  The  symptoms  during 
this,  the  dying  stage,  are  more  chronic  in  progress  when  necrosis  happens 
in  spongy  bone.  When  the  osseus  tissue  is  killed  at  once  the  symptoms 
of  this  stage  are  absent. 

The  stage  of  separation,  as  the  period  occupied  in  detaching  the  dead 
structure  may  be  termed,  has  characteristic  features. 

Chronic  discharge  from  the  cloacae  and  overlying  sinuses,  increased 


310  DISEASES    AND    INJURIES    OF    BONES. 

thickness  of  the  bone  and  gradual  impairment  of  health,  if  the  disease  is 
extensive,  are  the  most  jn'ominent.  Symptoms  of  waxy  degeneration  of 
the  liver  or  kidneys  may  arise.  The  time  occu])ied  in  separation  varies 
from  a  few  weeks  to  many  months  ;  being  shorter  in  the  upper  limb  than 
in  the  lower  and  when  the  necrosis  is  superficial  or  circumscribed  than 
under  opposite  conditions.  That  separation  has  been  accomplished  is 
known  by  the  motion  that  can  be  communicated  to  the  se<juestrum  by  a 
probe  passed  into  the  openings.  This  is  sometimes  better  determined  by 
introducing  two  probes,  one  near  each  end  of  the  sequestrum.  Sometimes 
the  sequestrum  is  not  movable,  even  when  completely  detached,  because 
it  is  imbedded  in  the  granulations  on  the  inner  surface  of  the  sheath.  If 
this  condition  is  suspected  a  strong  probe  should  be  used  to  force  the 
sequestrum  down  upon  the  granulations  until  they  are  flattened  and  the 
cavity  enlarged.     Motion  can  probably  then  be  detected. 

Prognosis. — The  prognosis  in  necrosis  as  to  final  restoration  of  the 
usefulness  of  the  part  is  generally  good,  except  in  acute  septic  cases.  The 
disease  seldom  extends  beyond  the  epiphyseal  cartilages,  and,  after  re- 
moval of  the  dead  bone,  the  sinuses  heal,  leaving,  however,  some  deformity 
in  contour.  Death  at  times  does  occur  in  the  early  stages,  as,  for  example, 
in  cases  following  acute  septic  osteomyelitis  or  periostitis ;  so  also  exhaus- 
tion from  prolonged  suppuration  or  pytemia  may  lead  to  a  fatal  issue. 
Again,  death  may  result  from  secondary  implication  of  other  structures. 
This  is  illustrated  by  brain  disease  following  necrosis  of  the  skull,  arthritis 
subsequent  to  disease  of  the  patella  and  laceration  of  the  femoral  artery 
by  necrotic  spicules  from  the  femur.  Pyiemia  from  moist  necrosis  is  not 
uncommon  ;  but  fortunately  this  form  of  bone  disease  is  quite  rare. 

Treatment. — The  indications  in  the  first  stage  are  to  moderate  accom- 
panying inflanimation  by  treating  thoroughly  the  causative  osteomyelitis 
or  periostitis,  to  open  abscesses  early,  and  to  keep  up  the  general  health. 
A  blister  will  sometimes  hasten  suppuration  and  thus  be  beneficial.  Early 
incision  of  the  jieriosteura  is  often  valuable,  since  it  relieves  pain  and  tends 
to  prevent  extensive  destruction  of  this  membrane  and  the  bone  by  sup- 
puration. So  trephining  the  inflamed  bone  and  scraping  away  the  diseased 
medullary  tissue  are  valuable  operative  procedures.  Disinfectant  solu- 
tions should  be  freely  employed  to  allay  fetor;  and  all  cases  should  be 
treated  with  rigid  antiseptic  measures.  As  soon  as  the  dead  bone  is  loose, 
it  should  be  removed  by  operation.  An  exfoliation  can  be  lifted  away 
with  a  chisel  after  simple  incision  of  the  musculo-cutaneous  coverings. 
When  the  bone  has  been  devitalized  by  caustics  or  burning,  and  the  dead 
area  is  easily  determined,  there  is  no  objection  to  cutting  it  away  w'ith  the 
chisel  even  before  detachment  has  taken  place,  for  it  hastens  the  cure.  A 
sequestrum  should  seldom  be  removed  until  it  is  entirely  loose.  To  effect 
its  removal  an  opening  should  be  cut  in  the  encasement  by  means  of 
small  sharp  chisels  and  a  hammer,  or  with  a  saw  or  trephine,  until  the 
sequestrum  can  be  seized  with  strong  forceps  and  pulled  out.  Sometimes 
the  cloacae  simply  need  enlargement ;  at  other  times  the  bridge  of  new 
bone  between  two  of  them  must  be  cut  away.  The  surgical  engine,  by 
which  circular  saws  and  burrs  can  be  rotated  with  great  rapidity,  may  be 
very  useful  in  these  procedures. 

After  application  of  the  Esmarch  apparatus  an  incision  should  be 
made  in  the  line  of  the  principal  sinuses  and  cloacse,  and  the  exposure  of 
the  bone  will  then  enable  the  surgeon  to  determine  upon  the  proper 
method  of  reaching  the  necrotic  piece.  The  encasement  should  be  freely 
cut,  but  in  such  a  manner  as  not  to  weaken  the  bone  more  than  necessary, 


NECROSIS    OR    MORTIFICATION    OF    BONE. 


311 


nor  to  fracture  it  transversely.  Occasionally  it  will  be  found  easier  to  get 
the  sequestrum  out  after  it  has  been  divided  into  portions  by  the  bone- 
cutting  forceps.  The  cavity  left  is  generally  lined  with  granulation  tissue, 
but  in  tubercular  subjects  its  walls  may  be  carious.  Such  carious  bone 
should  be  scraped  away  with  a  gouge.  In  getting  access  to  the  seques- 
trum, the  surgeon  should  not  feel  compelled  to  follow  the  sinuses  or  cloacae  ; 
any  safe  path  of  attack  which  gives  best  opportunity  for  thorough  removal 
is  justifiable. 

After  the  operation  is  completed  the  wound  should  be  stuffed  with  dry 
antiseptic  gauze,  the  limb  enveloped  in  a  similar  dressing,  and  a  roller 
bandage  firmly  applied  to  the  parts  before  the  elastic  band  of  the  Esmarch 
apparatus  is  removed. 

Subsequently  to  this  operation,  called  sequestrotomy,  the  encasement 
contracts,  new  bone  is  formed  in  the  cavity  of  the  sheath,  as  well  as  under 
the  preserved  periosteum,  and  the  sinuses  and  cloacse  become  closed.  The 
medullary  cavity,  if  destroyed,  is,  as  a  rule,  not  reestablished. 

There  are  some  circumstances  in  which  it  is  probably  better  to  operate 
before   detachment  of  the  sequestrum  is  complete,  notwithstanding  the 
possibility  of  thus  tearing  away  portions  of  the  living  bone.     This  is  the 
case  in  acute  necrosis  from  sub- 
periosteal abscess  and  septic  osteo-  Fig.  130. 
myelitis   and  in   moist   necrosis; 
for  more  extensive  destruction  of 
the    periosteum   and    septicemic 
complications    may    perhaps    be 
obviated  by  early  excision  of  the 
dead  structures  by  means  of  saws. 
The  periosteum  should  be  peeled 
off  and  preserved  in  these  opera- 
tions so  that  the  flail-like  limb, 
often   left,  may   have   an  oppor- 
tunity of  becoming  solidified  and 
useful.      An   objection   of   some 
force  against  waiting  too  long  for 

separation  in  ordinary  chronic  dry  gangrene  is  the  very  great  thickness 
of  the  encasement  that  occurs.  Three  to  six  months  is  probably  long 
enough  to  wait  in  the  majority  of  such  cases. 

Small  pieces  of  healthy  periosteum  or  of  bone,  taken  from  man  or  the 
lower  animals  and  kept  aseptic,  have  been  inserted  in  the  gaps  left  by 
extensive  operations  of  this  kind.  Such  bone  chips  act  as  centres  of  bone 
formation,  thus  hastening  and  perfecting  the  regeneration  of  the  removed 
shaft.  It  is  absolutely  essential  that  the  cavity  from  which  the  seques- 
trum has  been  taken  be  made  perfectly  aseptic  by  the  removal  of  every 
particle  of  diseased  bone,  diseased  granulations,  and  discharge.  Herein 
lie  the  difficulty  and  frequent  failure  of  the  method.  These  osteo-plastic 
operations  deserve  further  trial  in  cases  in  which  the  bone  has  been  exten- 
sively destroyed. 

The  methods  of  performing  sequestrotomy,  adopted  before  the  advent 
of  modern  antiseptic  surgery,  gave  good  results ;  though  the  healing  of 
the  remaining  wound  was  very  prolonged.  It  was  always  the  seat  of  pro- 
ti-acted  suppuration.  Septic  complications  were,  however,  uncommon; 
because  the  dense  inflammatory  infiltration  of  the  surrounding  osseous 
and  other  tissues  rendered  septic  absorption  difficult,  and  the  open  wound 
with  rigid  bony  walls  made  drainage  thorough  and  perfect. 


Diagram  of  a  transverse  section,  showing 
relations  of  sequestrum,  involucrum,  fistula 
and  skin.     (Geestee.) 


312 


DISEASES    AND    INJURIES    OF    BONES. 


Antiseptic  surgery  has  much  shortened  tlie  ])rocess  of  healing  by 
making  possible  the  implantation  of  cellulo-cutaneous  flaps  and  the 
organization  and  ossification  of  aseptic  blood-clots. 


Fig.  ISl. 


Neuber's  method.     Top  of  involucrum  removed,  skin  flaps  turued  into  the  bottom  of  tlie 
bone  cavity.     (Gerstkr.) 


Fi«.  132. 


Implantation  of  celhilo-cutaueous  Haps  may  be  done  in  order  to  cover 
the  fresh  surface  of  living  bone,  left  after  cutting  away  all  diseased  bony 

structure,  and  thereby  obtain  primary 
union  between  the  bone  and  the  turned- 
in  cutaneous  flaps.  This  leaves  little  or 
no  bony  surface  to  heal  by  granulation 
and  hastens  cicatrization ;  though,  of 
course,  a  defect  is  left  in  the  contour  of 
the  part.  This  defect  Avould  also  occur, 
even  if  the  process  of  implantation  was 
not  adopted.  The  turned-in  flaps  are 
held  in  position  by  sterilized  nails  driven 
through  the  flap  and  into  the  bone,  and 
by  sutures  passed  through  the  skin  at  the 
edges  of  the  cavity  and  carried  across 
the  gap;  or  by  sutures  carried  through 
the  edges  of  the  flaps  and  then  brought 
out  and  tied  upon  the  opposite  side  of 
the  limb.  These  different  methods  are 
shown  in  the  cuts  from  Gerster.  The 
nail  and  sutures  are  removed  at  the  end 
of  three  or  four  weeks;  which,  if  the 
wound  has  been  made  and  kept  aseptic, 
will  probably  be  the  date  of  first 
change  of  dressing. 
The  utilization  of  the  blood-clot  to  aid  in  rapid  cicatrization  is  accom- 
plished by  allowing  the  cavity  to  fill  with  blood,  which  dots  and  protects 
the  w^ouuded  bone  and  other  cut  surfaces  from  septic  irritation.  The 
clot  nuist,  however,  be  kept  aseptic  and  moist.  This  is  done  by  covering 
the  cavity  with  its  contained  clot  with  a  piece  of  aseptic  or  antiseptic 
rubber-tissue,  just  large  enough  to  overlap  the  borders  of  the  Avound. 
This  is  in  turn  covered  with  a  voluminous  dressing  of  dry  sublimate 
gauze.  The  rubber  tissue  keeps  the  blood-clot  moist,  the  dry  antiseptic 
dressing  absorbs  all  leakage  of  blood  and  serum. 


Implantation  of  cutaneous  edges 
into  the  defect  by  transfixing  catgut 
suture.    (Gerster.) 


CARIES,  OR  TUBERCULAR  ULCERATION  OF  BONE 


a3 


This  method  of  Schede  is  only  possible  ^yheu  the  entire  mass  or  all  the 
masses  of  necrotic  bone  are  removed,  when  all  the  pus-infected  membrane 
and  granulation  tissue  lining  the  irregular  tracks  and  cavities  have  been 
scraped  away  with  absolute  certainty,  and  when  the  cavities  so  made  have 
been  thoroughly  sterilized  by  sublimate  solutions  and  wiped  clean  with 
aseptic  sponges.  Gerster  recommends  sublimate  lotion  (1 :  500)  to  be  first 
used,  and  to  be  subsequently  washed  away  by  a  weaker  sublimate  solu- 
tion, so  that  toxic  effects  may  not  follow  the  retention  in  the  wound  of 
small  quantities  of  the  strong  lotion. 

Fig.  13.3. 


Schede's  method.     Diagram  sho^Mng  relations  of  oiganizing  blood-elot.    (Gerster.) 

If  it  is  impossible  to  remove  a  sequestrum,  excision  of  a  portion  of  the 
bone  or  of  the  joint  may  be  demanded.  When  the  destruction  of  bone 
has  been  very  great,  or  the  patient  is  already  sinking  from  exhaustion, 
due  to  long-continued  bone-disease,  amputation  may  be  the  most  judicious 
treatment. 

Caries,  or  Tubercular  Ulceration  of  Bone. 


Pathology. — The  inflammatory  disintegration  or  erosion,  called  caries, 
is  a  process  similar  to  ulceration  in  soft  tissues,  for  the  destroyed  structure 
is  removed  in  small  particles,  usually  in  a  more  or  less  liquefied  form. 
In  this  circumstance  caries  differs  from  necrosis,  in  which  the  devitalized 
portion  of  bone  is  separated  from  the  surrounding  living  osseous  tissue  in 
masses.  Caries,  therefore,  corresponds  with  ulceration  of  soft  tissues; 
necrosis  with  gangrene.  As  there  is  clinically  a  gangrenous  ulceration  of 
the  soft  parts,  in  which  the  two  processes  are  combined,  so  there  may  be  a 
necrotic  caries  of  bone.  Caries  occurring  without  formation  of  pus  is  the 
so-called  rarefying  ostitis,  or  dry  caries,  which  has  been  mentioned  when 
ostitis  was  discussed.  The  form  of  caries  most  often  seen  is  that  in  which 
the  inflamed  bone  softens  and  disintegrates  and  causes  the  so-called  "  cold 
abscess  "  within  or  upon  the  surface  of  the  bone.  It  is  due  to  infection 
with  the  tubercle  bacillus,  and  results  from  the  breaking  down  of  cheesy 
tubercles  and  inflamed  bone. 

Caries  is  the  result  of  bone  inflammation,  and  therefore  depends  upon 
the  constitutional  causes  that  induce  ostitis.  Ostitis  is  seldom,  if  ever, 
followed  by  liquefying  caries  unless  the  part  is  infected  with  the  tubercle 
bacillus.  Caries  is  often  associated  with  inherited  or  acquired  syphilis, 
but  it  is  possible  that  syphilis  may  not  be  the  actual  cause  of  the  caries, 
but  simply  a  cause  of  lowered  resistance  which  makes  tubercular  infection 


314  DISEASES    AM)    INJURIES    OF    BOXES. 

easy.  The  cancellated  tissue  found  in  the  extremities  of  the  long  bones 
and  in  the  vertebno,  carpus,  and  tarsus  is  especially  subject  to  the  invasion 
of  caries  in  those  predisposed  to  this  disease  ;  but  it  may  occur  in  any 
part  of  the  skeleton.  In  tubercular  persons  it  often  follows  injury.  An 
ulcer  of  the  soft  parts  may  involve  the  periosteum  and  bone,  and  lead  to 
caries. 

C  aries  causes  bone  to  become  softened,  porous  and  friable,  and  of  a 
gray  or  brownish  color  before  it  breaks  down  into  granular  semi-litiuid 
material.  Sometimes  the  mineral  constituents  are  dissolved  out  in  the 
early  stages  of  caries  leaving  the  animal  matter  almost  intact,  so  that  the 
condition  resembles  that  of  a  bone  after  maceration  in  hydrochloric  acid. 
The  organic  constituents  are  destroyed  sul)secjuently.  The  removal  of 
the  disintegrated  area  by  absorption  and  liquefaction  leaves  irregular 
hollows  and  cavities,  called  bone  ulcers,  which  are  occupied  by  the  puri- 
form  products  of  the  destructive  process.  The  bone  around  the  carious 
focus  is  apt  to  become  indurated,  because  Nature  endeavors  to  construct 
a  barrier  to  the  advance  of  the  diseased  action.  If,  however,  the  repara- 
tive power  of  the  patient  is  poor,  and  he,  from  some  inherent  constitu- 
tional tendency  is  especially  liable  to  bone  disease,  no  such  induration  or 
sclerosis  occurs,  and  the  carious  destruction  spreads,  involves  the  joints, 
and  attacks  adjacent  bones. 

Fig.  1;U. 


Caries  of  bone. 

The  products  of  carious  destruction  consist  of  oil  globules,  degenerated 
cells,  blood  corpuscles,  granular  inorganic  particles,  and  bone  salts,  with 
which  are  found  the  bacillus  of  tuberculosis.  The  products  are  the  results 
of  cheesy  degeneration  and  emulsification  of  the  osseous  tissue.  Small 
masses  of  necrosed  bone  will  sometimes  be  found  in  the  liquid,  where  the 
two  processes,  caries  and  necrosis,  have  coexisted.  Caseous  masses,  or 
tubercles,  will  be  found  in  the  interior  of  the  bone  tissue,  but  the  surface 
of  the  bone  is  usually  involved,  either  primarily  or  secondarily,  and 
localized  periostitis  and  intlamraation  of  the  overlying  soft  parts  arise. 
As  a  rule,  a  puriform  collection,  or  "  cold  abscess,"  subsequently  occurs 
in  the  tissues  over  the  bone,  which  spontaneously  opens  and  affords  an 
avenue  of  escape  for  the  liquefied  bone  material.  So  long  as  the  carious 
disintegration  continues  to  furnish  a  discharge,  the  sinus,  left  by  the  col- 
lapsed abscess,  will  not  permanently  close.  Septic  and  pyogenic  infec- 
tion frequently  occurs  secondarily,  and  contributes  to  this  condition.  The 
sinus  may  cicatrize  superficially,  because  but  a  small  amount  of  fluid  is 
formed  in  the  depths  of  the  track,  but  as  soon  as  a  few  drops  collect  the 
tissues  inflame  and  the  orifice  reopens.  Very  occasionallv,  as  in  some 
cases  of  caries  of  the  vertebral  bodies,  so  little  discharge  is  furnished  that 
it  is  entirely  absorbed,  leaving  no  caseous  or  puriform  deposition.  These 
may  be  called  cases  of  dry  caries. 

Bone  ulcers  heal,  as  do  ulcers  in  soft  parts,  by  granulation  and  cicatriza- 
tion.    The  loss  of  tissue  is  partially  or  entirely  replaced  by  a  granulation 


CARIES,  OR  TUBERCULAR  ULCERATION  OF  BONE.   315 

tissue  which  undergoes  ossification.  The  attempts  of  nature  to  fill  up  the 
cavities  left  after  caries  with  scar  tissue  may  be  quite  successful,  so  far  as 
utility  of  the  parts  is  concerned,  if  the  destruction  has  not  been  very 
great ;  but  depressions,  though  with  rounded  margins,  are  usually  left.  A 
great  deal  of  bone  is  often  formed  in  the  endeavor  to  fill  up  deep  cavities, 
which  remains  in  the  form  of  protuberances  and  bridge-like  masses.  The 
granulation  tissue  by  which  cicatrization  is  often  efifected  may  in  turn  be- 
come infected  with  the  tubercle  bacillus,  and  be,  therefore,  useless  as  a 
reparative  agent,  because  of  its  continuing  indefinitely  to  undergo  cheesy 
degeneration. 

Symptoms. — The  early  symptoms  are  necessarily  those  of  ostitis  and 
periostitis,  or  of  both,  and  are  followed  by  those  of  "  cold  abscess  "  of  the 
soft  parts.  When  this  puriform  collection  has  been  evacuated,  either 
spontaneously  or  by  incision,  the  cavity  does  not  promptly  heal,  but 
leaves  a  sinus  which  discharges  thin  puriform  fluid  continuously  or 
intermittently.  A  probe  passed  down  this  sinus  will  come  in  contact 
with  the  bared  and  roughened  bone,  if  the  track  is  not  too  crooked  to  be 
followed  to  its  bottom.  The  carious  surface  of  bone  is,  as  a  rule,  not 
tender  when  touched  with  the  instrument,  but  it  may  bleed.  If  it  is  im- 
possible to  feel  the  diseased  osseous  tissue  with  the  probe,  the  diagnosis 
may  be  made  by  persistent  failure  to  effect  permanent  healing  of  the 
sinus,  for  which  no  other  cause  exists,  and  by  chemical  examination  of 
the  fluid  showing  a  large  amount  of  calcium  phosphate.  The  discharge 
is  often  offensive  in  odor  because  of  putrefactive  infection,  and  contains 
gritty  particles  of  bone.  If  there  is  much  disease,  several  sinuous  tracks 
with  characteristic  orifices  surrounded  by  a  little  elevation  of  granulations 
will  probably  be  found  converging  toward  the  same  region  of  bone. 
"When  the  overlying  tissue  has  been  ulcerated  away,  the  diseased  bone 
will  be  exposed  to  view,  though  covered  in  places  more  or  less  completely 
with  fungous  granulation  tissue.  Coxitis,  angular  curvature  of  the  spine, 
called  Pott's  disease,  and  the  various  forms  of  joint  disease,  formerly 
called  white  swelling,  are  instances  of  caries  or  tuberculosis  of  bone. 

When  caries  attacks  bones  near  the  joints,  or  involves  the  articular 
ends  of  the  bone,  as  it  often  does,  ankylosis  is  likely  to  occur,  because  of 
inflammatory  involvement  of  the  joint  structures.  On  the  other  hand, 
the  tubercular  synovitis  may  occur  first,  and  lead  secondarily  to  caries  of 
the  bone  by  first  involving  the  articular  cartilages. 

Treatment. — Iodide  of  iron,  cod-liver  oil,  combinations  containing 
phosphoric  acid,  good  food,  healthy  surroundings,  sea  air,  and  similar 
therapeutic  and  hygienic  agents  are  essential  factors  in  the  management 
of  tuberculosis  in  bone.  Even  stimulants  may  be  required.  Antisyph- 
ilitic  remedies  are  often  required  in  full  and  long-continued  doses,  but 
combined  with  tonics. 

In  the  early  stages  while  the  disease  is  active,  cleanliness,  disinfection 
of  the  parts,  and  the  prevention  of  external  sources  of  irritation  or  infec- 
tion are  the  indications  for  local  treatment.  Eest  of  the  parts,  complete 
and  constant,  is  imperatively  called  for,  especially  when  the  vicinity  of 
a  joint  is  affected.  This  is  to  be  obtained  by  preventing  motion  by 
means  of  gypsum  or  silicate  of  sodium  splints,  by  permanent  extension,  and 
similar  mechanical  appliances.  This  does  not  necessarily  imply  that  the 
patient  must  be  kept  in  the  house  or  in  bed.  Confinement  is  often  dele- 
terious while  open-air  exercise  is  valuable. 

When  liquefaction  of  the  tubercle  occurs  free  incision  should  be  made 
for  the  escape  of  the  fluid,  and  the  whole  of  the  diseased  and  softened 


316  DISEASES    AND    INJURIES    OF    HONES. 

bone  should  cut  away  with  gouges.  This  should  be  done  autiseptically 
and  the  resulting  cavity  dusted  with  iodoform.  When  tlie  cavity  is  in- 
accessible or  very  larsje  it  may  be  injected  with  solution  of  iodoform  in 
ether  (1  :  20).  Of  this  from  1  to  3  Huidounces  should  be  u.sed  and  then 
squeezed  out  after  it  has  been  brought  in  contact  with  the  whole  interior 
of  the  cavity  in  the  bone  and  soft  parts.  The  possibility  of  iodoform 
poisoning  nuist  be  recollected,  if  large  ([uantities  are  used  in  cavities,  such 
as  those  of  psoas  abscess,  where  it  is  difficult  to  press  out  the  excess  of  fluid. 

Cure  can  often  be  hastened  by  the  early  operative  removal,  even  before 
liquefaction  has  occurred,  of  the  soft,  devitalized  bone  and  fungous  gran- 
ulation tissue,  which  impede  repair.  Natural  processes  can  eftect  the 
removal  of  this  material  only  after  the  lapse  of  many  weeks  or  months, 
and  the  protracted  discharge  necessitated  not  onl\'  debilitat'^s  the  patient, 
but  has  a  tendency  to  cause  waxy  degeneration  of  the  liver  and  kidneys. 
Sulphuric  or  hydrochloric  acid  diluted  with  equal  parts  of  water  has 
been  recommended  to  dissolve  away  the  softened  bone.  It  may  be  injected 
into  the  sinuses  or  brushed  upon  the  surfaces  exposed  by  a  flap  incision. 

If  the  bone  can  be  reached  by  incisions  not  too  extensive,  scraping 
away  the  spongy  and  devitalized  osseous  tissue,  and  the  fungous  granula- 
tions, is  more  prompt  and  sure.  To  do  this  effectually  Esmarch's  appa- 
ratus should  be  applied  to  prevent  hemorrhage  obscuring  the  view.  AV^ith 
a  gouge,  chisel,  scraper,  or  the  rotating  burr  of  the  surgical  engine  the 
surgeon  removes  the  unhealthy  structures.  The  operation  should  be  dis- 
continued when  healthy  bone  is  reached,  which  is  recognizable  by  its 
comparative  hardness,  and  the  hemorrhage  occurring  from  its  surface. 
When  the  healthy  bone  is  of  nearly  the  consistency  of  the  diseased  parts 
it  can  be  recognized  by  the  pink  color  due  to  its  vascularity.  The  cari- 
ous bone  when  washed  with  water  will  be  white,  gray,  or  black.  The 
possibility  of  general  tuberculous  infection  from  the  tuberculous  area 
leading  to  acute  tuberculosis  and  death,  is  a  factor  strongly  pointing  to 
operative  removal  of  the  local  tuberculous  focus  when  it  can  be  readily 
and  safely  done. 

In  extensive  caries,  excision,  arthreetoray,  or  amputation  may  become 
necessary,  but  these  capital  operations  should  not  be  done  hastily,  since 
caries  is  a  disease  of  chronic  type.  The  lapse  of  a  few  months  devoted 
to  a  general  constitutional  treatment  and  local  measures  may  change  a 
hopeless  looking  limb  or  joint  into  one  that  will  be  much  more  serviceable 
than  any  artificial  one.  The  possibility  of  fatal  exhaustion  from  the 
long  train  of  progressive  bone  disease  may  lead  one  to  amputate  at  a 
rather  early  date.  Passive  motion  of  joints  affected  with  tuberculosis 
may  be  cautiously  begun,  when  cure  seems  to  be  fully  instituted  by  the 
absence  of  heat,  pain,  and  discharge,  and  even  when  some  discharge  is 
present,  if  it  is  small  in  amount. 

While  believing  that  tuberculosis  of  bone  or  other  tissues  may  be  the 
local  disease  fi'om  which  general  infection  of  the  patient  may  occur,  I  am 
still  sure  that  cure  of  the  local  disease  and  subsequent  freedom  of  the 
patient  from  other  tubercular  infections  are  not  infrequently  obtainable 
without  operation.  It  is  here  that  good  judgment  and  experience  are 
valuable. 

Central  Cariks  or  Tubercular  Abscess  of  Bone. 

The  process  usually  called  circumscribed  "  suppuration "  of  osseous 
tissue,  or  "  bone  abscess,"  is  probably  more  common  than  is  usually  sup- 


TUBERCULAR    ABSCESS    OF    BONE. 


317 


posed.  Sucli  collections  of  puriform  fluid  are  instances  of  caries  and  are 
probably  always  due  to  the  tubercle  bacillus.  They  may  occur  in  any 
part  of  a  bone,  but  are  more  common  in  the  cancellated  structure  of  its 
extremities.  The  head  of  the  tibia  is  the  common  site.  These  tuber- 
cular collections  within  the  structure  of  the  bone  must  not  be  confused 
with  abscess  in  the  medullary  canal  and  suppurative  osteomyelitis,  which 
is  a  different  pathological  condition.  The  cavity  may  be  lined  by  a  soft 
membrane,  or  its  walls  may  be  roughened  carious  bone.  Sometimes 
there  is  a  narrow  track  or  sinus  leading  from  the  cavity  to  the  exterior 
of  the  bone,  which  in  such  a  case  would  possibly  have  a  carious  surface ; 
but  often  the  pus  is  completely  enclosed  in  a  bony  prison.  The  symptoms 
are  usually  very  chronic  in  their  progress  and  resemble  those  of  ostitis, 
which  is  to  be  expected,  as  so-called  abscess  is  merely  a  consequence  of 
tubercular  ostitis.  Long-continued  osseous  pain  distinctly  localized,  es- 
pecially if  near  the  extremity  of  a  long  bone  and  severe,  should  always  sug- 
gest abscess.  Circumscribed  myelitis,  necrosis,  and  cysts  within  the  bone 
structure  may  give  somewhat  similar  symptoms,  but  the  treatment  is 
similar  in  all  these  conditions  and  a  differential  diagnosis  is  not  very 
important.  Accompanying  periostitis  may  add  its  symptoms  to  those  of 
bone  abscess. 

Treatment  affords  prompt  relief  from  pain,  and  consists  in  dissecting  up 
the  soft  tissues  and  periosteum  and  applying  the  trephine  to  the  bone  at 
the  most  tender  spot,  so  as  to  open  the  cavity,  to  give  vent  to  the  puriform 
fluid,  and  to  permit  curetting  of  the  interior.  If  the  inner  surface  of  the 
wall  is  carious,  it  should  be  cut  away  with  the  gouge  or  burr ;  if  necrosis 
exists  the  sequestrum  should  be  re- 
moved. If  no  pus-like  fluid  is  found 
the  trephine  may  be  applied  at  an- 
other spot,  or  better,  perhaps,  a  drill 
may  be  made  to  perforate  the  bone  in 
various  directions  from  the  bottom  of 
the  first  trephine  hole. 

Trephining  should  always  be  done 
early,  as  it  is  at  once  followed  by  cure 
if  a  puriform  collection  is  present.  If 
no  fluid  is  present  the  operation  does 
no  great  harm,  and  will  probably  ame- 
liorate symptoms  by  decreasing  tension. 
If  no  collection  of  pus-like  fluid  is 
found  in  the  body  of  the  bone  it  is  well 
to  bore  into  the  marrow  cavity  before 
desisting,  as  it  is  possible  that  a  chronic 
medullary  abscess  may  be  the  cause  of 
the  symptoms.  The  wound  is  to  be 
well  drained  and  dressed  antiseptically. 

A  "bone  abscess"  may  open  spon- 
taneously into  a  neighboring  joint, 
causing  arthritis.  This  is  another 
reason  for  early  operation.  Acute  ab- 
scess of  the  medullary  canal,  or  acute  infective  osteomyelitis,  has  been 
discussed  in  the  preceding  section. 


Fig.  12 


Bone  abscess  in  which  trephining  was 
done  ,•  but  the  abscess  was  not  discov- 
ered at  the  operation,  a.  Trephine 
wound.     (Packard.) 


318 


DISEASES    AND    INJURIES    OF    BONES, 


Epiphysitis. 

Inflammation  of  the  cartilage  situated  between  the  shaft  of  ;i  bone  and 
its  epiphysis  occurs  at  times  in  children,  especially  in  those  of  low  vitality. 
The  inflammatory  bone  conditions  already  discussed  are  apt  to  be  asso- 
ciated with  epiphysitis,  though  it  is  possible  that  it  may  be  primary  in  its 
origin.  The  symptoms  are  similar  to  those  of  periostitis  and  arthritis, 
except  when  separation  of  the  epiphysis  and  the  preternatural  mobility 
and  crepitus  there  evoked  show  the  loss  of  the  uniting  cartihige.  Close 
scrutiny  will  usually  prevent  confounding  epiphysitis  with  arthritis.  The 
symptoms,  prognosis,  complications,  and  treatment  are  similar  to  what 
has  been  detailed  in  the  consideration  of  ostitis.  Early  and  free  incision, 
even  if  no  pus  is  suspected,  is  good  surgery.  Even  those  cases  that 
recover  without  extensive  destruction  of  tissue  are  apt  to  show  subsequent 
arrest  in  development  of  the  bone,  because  the  osteogenetic  function  of 
the  cartilage  has  been  impaired.  Tonics  and  nourishing  diet  are  neces- 
sary in  all  cases. 

Hypertrophy  and  Atuophy  of  Bone. 


Fig.  1.3(i. 


General  increase  of  a  bone  in  length  and  thickness,  to  which  the  name 
hypertrophy  is  often  applied,  is  in  most  cases  an  inflammatory  enlarge- 
ment due  to  chronic  ostitis,  periostitis,  and  epiphysitis.  Even  after  the 
inflammatory  process  has  subsided  the  bone  retains  its  increased  dimen- 
sions. This  is  not  hypertrophy  in  the  true 
pathological  sense.  Hypertroj^hy  may  occur, 
however,  when  unusual  functional  demands 
are  made  upon  a  bone.  An  instance  is  seen 
in  the  increased  size  and  strength  of  the  fibula 
occurring  when  the  tibia  has  been  destroyed 
by  necrosis. 

The  fibula,  being  gradually  called  upon  to 
support  unaccustomed  weight,  becomes  hyper- 
trophied  from  increased  functional  activity. 
A  localized  increa.se  in  bulk  of  a  bone  is  more 
proi)erly  called  an  osteoma  or  bony  tumor. 
Hypertrophy  of  bone  in  itself  neither  demands 
treatment  nor  is  amenable  to  it.  Exostoses 
and  other  forms  of  osteoma  may  he  excised  if 
disfigurement  or  other  reasons  make  operative 
treatment  desirable. 

Atrophy  of  bone  is  said  to  occur  in  two 
forms,  in  both  of  w'hich  there  is  decreased 
Aveight.  In  one  variety  the  bone  becomes 
smaller  in  size,  with  simultaneous  absorption 
of  the  cancellated  and  compact  tissue,  and 
diminution  of  the  calibre  of  the  medullary 
canal.  This  change  occui-s  after  long  disuse, 
as  in  stumps  after  amputation,  and  in  joints 
where  ankylosis,  dislocation,  or  paralysis  has 
long  existed.  It  is  observed  most  frequently 
in  the  long  bones,  and  is  a  not  uncommon  senile  change,  which,  when 
occurring  in  the  neck  of  the  femur,  may  jDroduce  shortening  of  the  limb 


Senile   atrophy  of  head   ami 
neck  of  thigh-bone.  (Gross.) 


SOFTENING    OF    BONE.  319 

and  lameness,  and  thus  simulate  fracture  at  that  point.  As  such  localized 
atrophy,  which  is  frequently  associated  with  fatty  degeneration,  may  hap- 
pen after  injuries,  the  practical  knowledge  of  this  possibility  is  great. 
Some  cases  of  so- called  atrophy  of  bone  may  be  imperfect  development, 
due  to  unrecognized  or  forgotten  injuries  or  disease  of  the  epiphyseal  car- 
tilages in  early  life.  In  the  other  form  of  atrophy  the  bulk  of  the  bone 
is  not  altered,  but  the  compact  osseous  tissue  gradually  becomes  rarefied 
and  changed  into  cancellated  structure,  whereby  the  bone  becomes  very 
light  and  brittle,  and  is  easily  broken  by  slight  injuries. 

The  distinction  between  atrophy  on  the  one  hand  and  interstitial  absorp- 
tion and  fatty  degeneration  of  bone  on  the  other  hand  is  perhaps  not  suffi- 
ciently observed.  The  absorption  of  bone  or  rarefying  ostitis  due  to 
pressure  of  tumors,  for  example,  does  not  appear  to  be  an  instance  of 
atrophy  in  as  true  a  pathological  sense  as  the  disappearance  of  the  alve- 
olar process  of  the  jaw  after  loss  of  the  teeth.  It  is  true  that  in  the 
former  case  the  thinning  and  erosion  may  be  due  to  interference  with 
circulatory  and  nervous  supply,  causing  atrophic  change  ;  but  the  dimin- 
ution of  structure  following  disuse  corresponds  more  nearly  with  the  idea 
of  atrophy. 

Treatment  is  of  no  avail  in  curing  osseous  atrophy.  In  cases  where 
the  function  can  be  restored,  as  in  ankylosis  of  long  duration,  the  bone 
may,  however,  regain  some  of  its  lost  bulk. 


Osteomalacia.     Softening  of  Bone. 

This  very  rare  affection,  also  called  mollities  ossium,  seems  to  be  a  gen- 
eral disease,  though  the  chief  changes  are  found  in  the  skeleton.  Its 
nature  is  exceedingly  obscure.  Some  authors  have  suggested  a  possible 
identity  with  fatty  degeneration,  malignant  degeneration,  or  atrophy  of 
bone.  Others  have  called  it  rickets  of  adults,  since  it  resembles  rickets, 
but  has  been  observed  only  in  adults. 

The  clinical  characteristic  of  the  disease  is  progressive  softening  of  the 
bones,  which  become  so  soft  that  a  knife  can  readily  cut  them.  At  the 
same  time  they  lose  weight  and  are  either  flexible  or  easily  broken. 
Various  portions  of  one  bone,  and  as  a  rule  many  parts  of  the  skeleton, 
are  afi'ected.  The  external  compacic  portion  becomes  little  more  than  a  thin 
shell,  while  the  cancellated  structure  has  become  more  spongy  than 
normal  and  filled  with  a  reddish,  gelatinous,  fatty  material.  The  earthy 
constituents  of  the  bone  have  been  removed  by  a  process  of  decalcifica- 
tion, and  a  sort  of  mucoid  degeneration  of  the  animal  portion  of  the 
osseous  structure  has  apparently  occurred.  The  medullary  tissue  is  at 
the  same  time  very  vascular.  Lactic  acid  has  been  described  as  found  in 
the  bony  tissue  and  in  the  urine. 

Osteomalacia  is  more  frequently  seen  in  women  than  in  men  and  seems 
to  be  induced  by  pregnancy.  It  is  a  disease  of  adult  life.  The  pro- 
longed administration  of  lactic  acid  has  been  mentioned  as  a  possible 
cause. 

The  symptoms  are  pain  of  a  rheumatoid  character  and  a  tendency  of 
the  bones  of  the  extremities  or  trunk  to  bend  like  softened  wax.  If  the 
compact  outer  tissue  of  the  bone  is  not  much  decalcified,  however,  brittle- 
ness  instead  of  flexibility  will  be  present  and  fractures  from  slight  injuries 
will  frequently  occur.  The  urine  usually  contains  a  remarkable  amount 
of  phosphates,  evidently  derived   from    the   degenei^ating   bone   tissue. 


320  DISEASES    AND    INJURIES    OF    BONES. 

Phosphates  have  l>oen  found  also,  it  is  said,  in  the  saliva,  tears,  and  other 
tiiiids.  Albuminuria  has  been  observed.  The  patient  finally  becomes 
bedridden,  because  locomotion  is  impossible,  and  dies  exhausted.  Osteo- 
malacia, unlike  rickets,  is  painful,  never  occurs  in  children,  and  progresses 
until  death  occurs.  The  softened  bones  of  rickets  usually  become  hard 
again  ;  such  is  not  the  case  in  osteomalacia.  There  is  no  efficient  treat- 
ment known.  Phosphates  of  lime,  sodium,  and  potassium  with  cod-liver 
oil  and  tonics  should  be  administered.  Bedsores  should  be  expected,  and 
prevented  if  practicable. 

Tumors  in  Bone. 

Bones  may  become  the  seat  of  tumors  of  various  kinds,  such  as  sar- 
coma, osteoma,  chondroma,  fibroma,  angioma,  myxoma,  and  hydatid  cysts. 
It  was  formerly  believed  that  carcinoma  was  a  not  infreiiuent  growth  in 
osseous  tissue.  Such  is  not  the  fact.  Except  when  it  occurs  secondarily 
to  carcinonm  in  other  structures  this  form  of  neopl.asm  is  practically 
unknown  in  bone.  .Sarcoma,  however,  is  common.  True  cystic  tumors 
are  seldom  found  except  in  the  jaw  bones,  where  they  are  at  times  devel- 
oped from  the  mucous  membrane  of  the  antrum  and  the  structures  about 
the  teeth.  Tumors  containing  fluid  found  in  other  bones,  unless  hydatid 
cysts,  are,  as  a  rule,  sarcomas,  chondromas,  or  myxomas  which  have  under- 
gone cystic  degeneration.  Vascular  tumors,  that  is  to  say,  angiomas, 
are  occasionally  seen ;  but  the  pulsating  tumors  formerly  described  as 
aneurisms  of  the  arteries  in  bone  are  probably  always  highly  vascular 
sarcomas. 

Tumors  of  bone  may  be  developed  from  the  lower  layer  of  the  perios- 
teum or  from  the  medulla  or  endosteum.  Periosteal  growths  are  usually 
oval  or  pyriform  in  shape,  of  a  smooth  surface,  and  have  a  capsule  derived 
from  the  periosteum.  The  adjacent  bone  may  be  normal,  hardened,  ab- 
sorbed, eroded,  or  fractured.  The  growth,  if  malignant,  may  spread  to 
the  medulla  by  the  Haversian  canals.  Endosteal  or  central  tumors  are 
usually  spherical,  smooth  on  the  surface,  and  when  handled  may  give  rise 
to  a  crackling  sound.  The  enlargement  of  the  growth  causes  disappear- 
ance of  the  bone,  but  the  periosteum  becoming  inflamed  constantly  forms 
new  layers  of  bone  tissue.  These  are  absorbed  in  turn,  but  new  plates 
of  osseous  tissue  are  continually  developed.  Thus  the  mass  acquires  a 
more  or  less  bony  capsule,  and  when  the  patient  is  examined  a  crackling 
sound  is  elicited  by  the  motion  imparted  to  the  membrano-osseous  encase- 
ment. This  is  the  explanation  of  the  apparent  dilatation  of  the  bone 
and  the  parchment-like  crackling  elicited  by  pressure. 

Non-malignant  growths  in  bone  do  no  harm,  as  a  rule,  other  than  to  act 
as  impediments  to  motion,  and  to  cause  deformity.  They  may  be  excised 
with  chisels  and  saws  if  such  action  is  demanded  by  the  disability  or  dis- 
figurement. Sarcomas  spread  into  the  surrounding  parts  and  involve  dis- 
tant structures  by  secondary  involvement  through  the  blood-current. 
Amputation,  early  and  at  a  considerable  distance  above  the  disease,  is 
always  demanded. 

Ix.iuRiES  OF  Bones. 

Bone,  together  with  its  periosteum  and  marrow,  may  receive  contused, 
incised,  lacerated,  and  punctured  wounds.  Such  wounds  of  bone  are  fre- 
quently obtained  in  war  from  bullets,  balls,  sabres  and  arrows,  and  occa- 
sionally are  seen  in  civil  practice.     Fractures  are  lacerated  wounds  of 


FRACTURES.  321 

bone,  and  are  common  everywhere.  Osseous  wounds  are  followed  by  peri- 
ostitis, ostitis,  and  osteomyelitis,  which  may  be  localized  or  diffused.  The 
wounds  should  be  treated  as  similar  wounds  of  soft  parts  and  their  se- 
quences on  the  principles  detailed  in  the  section  on  diseases  of  bone. 
Fractures,  Avhich  are  wounds  or  solutions  of  continuity,  usually  involving 
the  entire  thickness  of  the  bone  injured,  will  be  discussed  in  the  following 
section  of  this  treatise.  Contusions  of  bone  may  become  of  grave  import, 
when  a  viscus,  such  as  the  brain,  within  the  bony  case,  is  simultaneously 
or  secondarily  involved,  or  when  atrophy  of  the  bone,  as  in  the  neck  of 
the  femur,  is  so  induced.  The  induction  of  osteomyelitis  by  contusion  is 
another  serious  complication  of  what  may  seem  a  trivial  injur3\ 

Bending  without  fracture  occurs  at  times  in  very  young  bones  or  in 
those  softened  by  rickets  or  osteomalacia.  The  treatment  is  to  bend 
them  forcibly  into  proper  shape,  or  to  do  so  gradually  by  means  of  well- 
padded  splints  or  the  elastic  tension  of  rubber  straps.  Muscular  action 
or  the  elasticity  of  the  bone  may  correct  such  deformity  in  children  with- 
out much  treatment.  The  surgeon  should  not  hesitate  to  straighten  such 
bones  by  making  a  complete  fracture  if  there  is  a  probability  of  perma- 
nent deformity. 

Fractures. 

Definition. — A  fracture  is  a  sudden  breaking  or  tearing  apart  of 
osseous  fibres;  in  other  words,  a  lacerated  wound  of  bone. 

A  solution  of  continuity  due  to  disease  or  to  division  by  saws  or  sharp 
instruments  is  not  a  fracture,  though  in  its  treatment  and  mode  of  repair 
it  may  be  similar.     The  term  fracture  is  also  applied  to  breaking  of  car-  . 
tilaginous  tissue. 

Causes. — For  the  production  of  a  fracture  an  exciting  cause  must 
always  be  present,  but  certain  characteristics  of  the  patient  or  of  the 
special  bone  may  act  as  predisposing  causes.  The  atrophy  of  bone  occur- 
ring in  old  age  and  in  the  subjects  of  locomotor  ataxia,  osteomalacia, 
rickets,  and  malignant  diseases  of  bone,  are  efficiently  predisposing  causes, 
for  they  render  the  bony  tissue  less  able  to  resist  strain.  Syphilis  and 
tuberculosis  have  been  called  predisposing  causes,  but  probably  on  insuffi- 
cient evidence.  General  paralysis  of  the  insane  seems  to  be  associated 
with  brittleness  of  bones.  This  is  probably  due  to  atrophic  changes  in 
the  osseous  structure.  Stimson  states  that  the  greater  fragility  of  bone  in 
the  aged  is  to  be  attributed  to  senile  atrophy,  and  not,  as  is  often  asserted, 
to  a  greater  relative  proportion  of  inorganic  material.  A  bone,  by  reason 
of  its  exposed  position,  its  curves,  its  function  as  a  lever,  or  its  small  pro- 
portion of  compact  osseous  tissue,  may  be  more  liable  to  suffer  fracture 
than  the  adjacent  pieces  of  the  skeleton.  On  the  other  hand,  a  flat, 
movable  bone,  surrounded  by  muscles,  such  as  the  scaj)ula,  is  very  unlikely 
to  be  broken. 

The  exciting  causes  of  fracture  are  external  violence  and  muscular 
action.  External  violence  is  said  to  act  directly  when  the  bone  is  broken 
at  the  point  of  impact.  It  is  a  crushing  force  that  causes  disruption  of 
the  osseous  fibres  in  these  cases.  Gunshot  fractures  and  fractures  caused 
by  kicks  and  by  falling  timbers  are  thus  produced.  External  violence  is 
said  to  act  indirectly  when  the  fracture  occurs  not  at  the  point  struck, 
but  at  some  distant  part  of  the  skeleton.  The  force  is  transmitted  thither 
through  the  intervening  bones,  and  tears  the  bony  fibres  apart  by  lever- 
age, torsion  or  traction.     Muscular  action  is  not  a  very  frequent  cause  of 

21 


322 


DISEASES    AND    INJURIES    OF    BONES. 


fracture  excej)!  in  fracture  of  the  patella.  That  powerful  niusculai-  cou- 
tractions  may  cause  fracture  of  long  bones  is  proved  by  instances  occur- 
ring in  athletic  persons  during  elforts  of  throwing  or  lifting.  Similar 
injuries  have  been  reported  as  taking  place  during  tetanic  or  ej)ileptic 
spasm  of  muscles.  Fracture  of  the  patella,  olecranon,  of  the  posterior  end 
of  the  calcaneuni  and  of  the  coracoid  process  of  the  scapula  is  usually 
due  to  powerful  muscular  action. 

Breaking  of  the  patella  by  contraction  of  the  four-headed  extensor  of 
the  leg  may  possibly  be  at  times  rendered  more  easy  on  account  of  lever- 
age action  exerted  upon  the  bone  as  it  lies  in  contact  with  the  condyles  of 
the  femur.  Stirason,  however,  believes  that  it  is  usually  a  giving  way,  as  a 
rope,  from  direct  traction,  exerted  by  the  muscle.  The  muscles,  by  hold- 
ing the  bones  in  fixed  positions,  may  indirectly  assist  external  violence  in 
causing  fractures.  This  will  be  understood  by  considering  that  a  cadaver 
thrown  from  a  height  is  less  likely  to  sustain  fracture  than  is  a  living 
body. 

Fractures  occasionally  take  place  in  the  uterus  ;  due  usually  to  violence 
inflicted  upon  the  foetus  by  injuries  received  upon  the  abdomen  of  the 
mother.  A  rachitic  fetus  is  prone  to  suffer  such  osseous  lesions  from  com- 
paratively slight  force.  It  is  possible,  however,  that  some  supposed  intra- 
uterine fractures  are  really  instances  of  defective  ossification. 

Varieties. — There  are  two  kinds  of  fractures ;  the  open  and  the 
closed.  The  open  fracture  is  one  in  which  the  broken  surfaces  are  ex- 
posed to  atmospheric  contact  by  reason  of  a  communication  with  the 

Fig.  137. 


U'Vi 


Fig.  1.38. 


Diagram  of  coinininuted  fracture. 


Impacted  fracture  of  neck  of  femur. 
(Mutter  Museum.) 


surface  through  a  wound  of  the  muscles,  fascia,  and  skin.  A  closed 
fracture  is  one  with  which  no  such  wound  coexists,  and  which  is  therefore 
protected  from  atmospheric  influences.  The  former  are  often  called  com- 
pound fractures :  the  latter  simple  fractures.     As  these  terms  are  not 


FRACTURES. 


323 


self-explanatory  and  are  otherwise  objectionable,  they  should  be  dis- 
carded. Closed  fractures  are  sometimes  denominated  subcutaneous  frac- 
tures. This  use  of  the  word,  though  convenient,  is  misleading,  because  it 
seemingly  implies  that  the  fracture  is  an  open  one  whenever  the  skin  in 
the  vicinity  of  the  fracture  is  laid  open.  Such  is  not  the  fact.  Com- 
munication with  the  air  is  the  requisite  of  an  open  fracture ;  hence  the 
muscles  and  fascia,  as  well  as  the  skin  or  mucous  membrane,  must  be 
perforated  or  divided. 

The  open  character  of  a  fracture  may  be  due  to  the  vulnerating  force 
causing  laceration  of  the  soft  parts,  to  its  continuance  inducing  protrusion 
of  the  fragments,  to  the  weight  of  the  unsupported  limb  giving  rise  to  a 
similar  protrusion,  or  to  secondary  ulceration  and  suppuration. 

Open  fractures  are  much  more  serious  than  closed  fractures,  because 
pyogenic  bacteria  gain  admission  to  the  wound  and  suppuration  generally 
occurs  about  the  ends  of  the  fragments.  Union  is,  therefore,  less  rapid, 
and  osteomyelitis  of  a  severe  type  and  septicsemia  are  more  likely  to 
arise.  The  modern  or  antiseptic  methods  of  surgery  have  rendered  open 
fractures  as  little  liable  to  these  complications  as  were  closed  fractures 
formerly. 

Fig.  139. 


(a)  Transverse  fracture  and  (6)  oblique  fracture.     (Hamilton.) 

Various  terms  are  applied  to  both  open  and  subcutaneous  fractures  to 
indicate  the  characteristics  of  the  broken  structure :  A  comminuted  frac- 
ture is  one  in  which  several  inter-communicating  lines  of  fracture  split 
the  bone  into  a  number  of  comparatively  small  fragments.  If  a  bone  is 
broken  at  two  or  more  different  places  and  the  lines  of  fracture  do  not 
run  into  each  other,  the  injury  is  a  double  or  triple  fracture,  not  a  com- 
minuted one. 

In  an  impacted  fracture  one  fragment  is  driven  into  the  cancellated 


324 


DISEASES    AND    INJURIES    OF    BONES. 


structure  of  the  other  and  firmly  fixed  there.  It  is  rather  rare,  and  can 
only  occur,  as  a  rule,  at  the  extremity  of  bones  where  there  is  much  can- 
cellated tissue.  The  lower  end  of  the  radius  and  the  neck  of  the  femur 
are  the  localities  in  which  it  is  likely  to  be  seen. 

In  a  transverse  fracture  the  ])lanc  of  fracture  makes  a  right  angle,  or 
at  least  au  angle  of  not  less  than  70°,  with  the  long  axis  of  the  bone. 
Transverse  fractures  are  rare,  except  in  the  patella  antl  at  the  lower  end 
of  the  radius,  and  when  observed  are  usually  caused  by  either  direct 
violence  or  muscular  cimtractiou.  They  are  probably  more  common  in 
children  and  the  very  aged  than  at  other  periods  of  life. 


Fig.  140. 


Fig.  141. 


^«pifiiimii'|iiii""-" 


Longitudinal  fracture.     (Stimson.)         IiicDiaplete  tVariure  of  femur.     (Guri.t.) 


Longitudinal  fractures  are  those  in  which  the  line  of  fracture  is  not 
further  from  the  long  axis  of  the  bone  than  15°  or  20°.  They  are  very 
rare,  except  as  accompanying  such  perforating  fractures  as  are  caused  by 
gunshot  injuries. 

Oblique  fractures  are  those  in  which  the  line  of  separation  is  neither 
transverse  nor  longitudinal.     The  majority  of  fractures  are  oblique. 

A  complete  fracture  of  a  long  bone  crosses  the  long  axis  of  the  shaft 
and  divides  the  bone  into  two  or  more  pieces.  A  fracture  of  a  flat  bone 
to  be  complete  must  involve  its  entire  thickness.  Under  the  head  of  in- 
complete or  partial  fractures  of  long  bones  are  included  the  so-called 
"green-stick  "  fractures,  in  which  some  fibres  are  torn  and  others  bent, 
fissures,  separation  of  mere  splinters,  detachment  of  bony  prominences, 
and  perforating  fractures,  such  as  are  made  by  bullets.  Indentations  of 
flat  bones  by  forces  not  sufficient  to  cause  fracture  through  the  entire 
thickness,  are  instances  of  incomplete  fracture. 

Incomplete  fractures  may  become  very  serious  injuries;  for  example. 


FRACTURES. 


325 


fissures  communicating  with  the  marrow,  if  open  to  the  external  air  and 
infected  with  putrefactive  or  pyogenic  germs,  may  be  followed  by 
dangerous  osteomyelitis.  The  injury  sometimes  called  "  sprain  fracture," 
in  which  a  small  fragment  of  bone  is  torn  away  at  the  point  where  a 
ligament  is  attached,  is  an  incomplete  fracture.  Rupture  of  the  main 
artery,  laceration  of  the  chief  nerve,  extension  of  the  line  of  fracture  into 
a  joint,  dislocation,  and  other  lesions  may  occur  simultaneously  with  a 
fracture  and  complicate  the  treatment. 

A  diastasis,  or  forcible  separation  of  an  epiphysis  from  the  shaft  of  a 
bone,  presents  the  symptoms  of  a  fracture,  and  requires  like  treatment. 
Ossification  of  all  the  epiphyseal  cartilages  has  usually  occurred  before 
the  twenty-fifth  year ;  hence  epiphyseal  fracture  or  separation  can  rarely 
happen  at  a  later  period  of  life  than  this.  The  line  of  separation  is  of 
necessity  usually  transverse ;  and  commonly  some  scales  of  bone  are  torn 
from  the  shaft  with  the  layer  of  cartilage.  The  innominate  bone  may  be 
separated  by  injury  into  its  three  primary  segments  by  a  similar  separa- 
tion through  the  cartilages.  Arrested  growth  is  not  unusual  after  epiphy- 
seal detachments. 


Fig.  U2. 


Fig.  143. 


i& 


Fissure  of  humerus.     (Gurlt.) 


Diastasis,  or  epij^hyseal  separation  of  the  head 
of  humerus.     (Moore.) 


Pathology. — When  a  bone  is  broken  hemorrhage  occurs  from  the 
arteries  and  veins  in  the  Haversian  canals  and  medullary  cavity,  and  the 
periosteum  is  more  or  less  extensively  lacerated.  The  muscles  and  fascia 
about  the  seat  of  fracture  are  usually  implicated  in  the  violence,  even  in 
closed  fractures  with  little  displacement ;  hence  extravasation  of  blood  in 
and  from  the  surrounding  soft  parts  is  common.  The  blood  from  the  torn 
soft  parts  usually  shows  as  a  blue  discoloration  of  the  skin  a  few  hours 
after  the  injury.  That  effused  from  the  osseous  structure  itself  does  not 
reach  the  surface  for  two  or  three  days,  because  it  can  only  leak  through  the 


326  DISEASES    AND    INJURIES    OF    BONES. 

deep  fascial  coverings  by  means  of  small  oj)enings  existing  where  nerves 
and  bloodvessels  approach  the  exterior.  By  gravitating  or  travelling 
under  fascial  or  muscular  layers  it  may  appear  quite  far  from  the  locality 
of  fracture. 

The  periosteal  laceration  may  correspond  with  the  line  of  fracture,  but 
this  is  uncommon,  because  the  majority  of  fractures  are  oblique,  and 
in  them  the  periosteum  is  apt  to  be  stripped  up  from  the  bone  in  the 
vicinity  of  the  fracture  before  it  gives  way  under  the  tension  of  the  dis- 
rupting force.  This  renders  the  line  of  tear  irregular.  In  comminuted 
fractures  some  of  the  fragments  may  be  held  in  position  by  untorn  peri- 
osteum, while  others  are  entirely  denuded  of  this  membrane.  The  latter 
are  not  aj)t  to  become  necrotic  unless  the  wound  is  infected  with  micro- 
organisms. Very  occasionally  it  haj)pens  that  a  bone  is  broken  and  the 
periosteum  left  intact  or  nearly  so.  Little  displacement  then  occurs  and 
rapid  cure  without  deformity  is  to  be  expected. 

Around  the  locality  of  fracture  inflammatory  processes  at  once  occur, 
varying  in  intensity  with  the  severity  of  the  damage  done  to  the  bone 
and  the  soft  parts.  The  interference  with  return  circulation  caused  by 
the  pressure  of  the  inflammatory  products  may  give  rise  to  oedema  of  the 
distal  portion  of  the  limb,  even  in  cases  of  fractures  of  very  moderate 
gravity.  The  fever  and  other  general  symptoms  depend  on  the  type  and 
degree  of  the  inflammatory  action.  Albumin,  tube  casts,  and  fat  have 
been  observed  in  the  urine  of  patients  suffering  with  fractures,  apparently 
as  a  sequence  of  the  osseous  injury.' 

The  fragments  of  bone,  except  in  ca.*es  of  mere  fissure,  seldom  retain 
their  normal  position.  Continuance  of  the  injuring  force  for  a  moment 
after  the  disruption  of  the  bone  has  occurred,  attempts  to  use  the  injured 
member,  as  in  walking,  dropping  of  the  unsupported  limb  below  the 
injury  because  of  its  intrinsic  weight,  and  tonic  or  spasmodic  muscular 
contraction  are  all  displacing  causes.  Fractures  in  children  show  less 
displacement  than  those  in  adults,  because  greater  elasticity  of  the  bone 
makes  the  line  of  fracture  more  irregular  and  therefore  the  fragments  are 
more  apt  to  remain  interlocked.  Moreover,  the  periosteum  is  le.ss  com- 
pletely torn  and  the  muscles  are  less  powerful. 

Angular,  rotary,  transverse,  or  longitudinal  deviation  may  occur  at  the 
seat  of  fracture.  Usually,  however,  the  displacement  is  a  combination 
of  these  malpositions.  Occasionally,  as  in  some  comminuted  fractures, 
the  displacement  is  too  complex  in  its  nature  to  be  classified  under  these 
heads.  As  a  rule,  it  is  the  distal  fragment  that  occupies  the  abnormal 
position.  Transverse  fracture  of  the  patella,  fracture  of  the  olecranon, 
and  similar  injuries  afford  exceptions  to  this  rule.  Angular  displacement 
or  tilting,  in  which  the  axes  of  the  fragments  form  an  obtu.se  angle,  is 
typically  represented  in  green-stick  fractures  and  bending  of  bones,  in 
which,  indeed,  it  is  the  only  form  of  malposition  possible.  In  rotary  dis- 
placement one  fragment  is  twisted  on  its  long  axis.  A  good  example  is 
fracture  of  the  shaft  of  the  femur  in  its  upper  third.  Here  the  weight 
of  the  limb  usually  rotates  the  lower  part  of  the  bone  outward.  When 
one  fragment  is  displaced  laterally  or  an tero-posteriorly,  transverse  devia- 
tion exists.  This  form  of  displacement  seldom  happens  except  in  com- 
bination with  one  of  the  other  varieties.  It  may  occur  alone,  however, 
in  transverse  and  serrated  fractures.     If  the  ends  of  the  fragments  slip 

1  Riedel,  quoted  by  Stimson,  Treatise  oil  Fractures,  111. 


FRACTURES. 


327 


past  each  other  the  muscular  tonicity  causes  overlapping,  unless  an  un- 
broken parallel  bone,  as  in  the  leg  or  forearm,  prevents  its  occurrence. 


Fig.  144. 


Fig.  145. 


Fig.  146. 


Fig.  147. 


Fig.  144. — Diagram  of  angular  displacement. 
Fig.  145  — Diagram  of  rotary  disjDlaeement. 
Fig.  146. — Diagram  of  transverse  displaceinent. 
Fig.  147. — Diagram  of  (a)  longitudinal  displacement: 


(b)  impaction. 


Longitudinal  displacement  is  a  change  made  in  the  long  axis  of  the 
bone.  It  consists  in  overlapping  of  the  fragments,  in  penetration  of  a 
broad  fragment  by  a  narrow  one  (impaction),  or  in  actual  crushing  of  the 
osseous  structure  into  small  pieces.  In  rare  instances,  as  in  fracture  of 
the  patella  and  olecranon,  the'  longitudinal  deviation  consists  in  separation 
of  the  pieces  of  bone.  This  is  dependent  upon  a  powerful  muscular 
attachment  to  one  of  the  fragments.  Muscular  action  in  nearly  every 
other  fracture  causes  shortening.  It  is  not  always  possible  to  predict  the 
character  and  extent  of  displacement  that  will  occur  in  a  fracture  at  a 
given  locality,  for  it  depends  on  the  direction  and  nature  of  the  line  of 
fracture  as  well  as  on  the  muscular  attachments  and  other  above-men- 
tioned causes  of  deformity.  All  the  forms  of  displacement  occur  in  a 
marked  degree  in  oblique  fractures,  while  little  deviation  is  seen,  as  a 
rule,  in  transverse  ones. 

Symptoms. — A  case  of  suspected  fracture  should  be  examined  as  soon 
as  practicable  after  the  receipt  of  the  injury,  unless  the  intensity  of  ner- 
vous collapse  or  some  similar  circumstance  makes  such  examination  more 
hurtful  than  a  few  hours'  delay  in  determining  the  exact  character  of  the 
injury.  When  a  case  is  not  seen  until  some  days  after  the  accident  and 
very  violent  inflammation  has  already  supervened,  it  may  be  wise  to  wait 
a  day  or  two  and  endeavor  to  lessen  the  inflammatory  symptoms  before 
undertaking  the  manipulations  necessary  to  establish  an  accurate  diag- 
nosis. In  obscure  cases  ansesthesia  should  be  induced  that  a  thorough 
examination  may  not  be  prevented  by  reason  of  pain.  In  order  to  give 
the  patient  time  to  recover  equanimity  after  the  sui'geon's  entrance,  as 
well  as  to  learn  the  facts  of  the  case,  questions  concerning  the  accident 
should  be  asked  before  the  examination  is  begun.  If  this  is  not  done  the 
nervous  excitement  due  to  pain  from  the  examination  or  the  insensibility 
of  ansesthesia  will  make  the  obtaining  of  definite  answers  impossible.  The 
possibility  of  deformity  from  previous  injuries  and  the  history  of  the 
case  should  be  fully  considered.  The  surgeon  should  then  grasp  the 
parts  firmly  and  examine  carefully  and  thoroughly  for  deformity,  abnor- 
mal mobility,  crepitus,  and  any  other  objective  symptoms  necessary  to 
establish  a  diagnosis.  Needless  repetition  of  movement  is  to  be  depre- 
cated as  much  as  inefiicient  firmness  of  grasp  during  the  manipulation  is 


328  DISEASES    AND    INJURIES    OF    BONES. 

to  be  avoided.  A  wound  near  the  seat  of  fracture  should  be  cautiously 
explored  with  the  finger  and  probe  to  see  whether  the  fracture  is  an  open 
or  closed  one.  If  oil  globules  escape  from  the  wound  within  twelve  hours 
the  wound  probably  connects  with  the  fracture.  It  is  the  injured  marrow 
that  furnishes  this  fat.  A  good  deal  of  venous  oozing  is  also  suggestive 
of  the  fracture  being  an  o})en  one,  because  the  veins  of  solt  tissue  cease 
bleeding  .sooner  than  those  of  bone.    The  latter  cannot  collapse  so  readily. 

The  symptoms,  which,  whin  occurring  together,  make  the  evidence  of 
fracture  conclusive,  are:  deformity,  abnormal  mobility,  and  crepitus  or 
grating.  One  is  often  sufficient  to  establish  the  diagnosis,  l)ut  their 
coexistence  is  pathognomonic.  If  one  of  these  symptoms  gives  unmistak- 
able evidence  of  fracture,  it  is  often  well  to  desist  from  endeavors  to 
develop  the  others,  since  such  action  but  adds  to  the  i)ain,  and  may 
increase  the  displacement  of  the  fragments.  In  many  fractures  one  or 
two  of  these  symptoms,  as  will  be  shown  subsequently,  may  be  absent. 

Deformity  is  principally  due  to  the  displacement  of  the  fragments. 
Extravasation  of  blood  may  aid  in  the  primary  deformity,  and  intlamraa- 
tory  swelling  in  that  which  occurs  later.  The  forms  of  displacement, 
which  have  been  already  discussed  on  a  i)revious  page,  may  give  rise  to 
marked  or  very  slight  deformity.  Slight  deformities  are  often,  however, 
much  more  difficult  to  correct  than  great  ones.  When  the  periosteum  is 
slightly  torn  there  is  no  deformity,  because  this  fibrous  membrane  retains 
the  fragments  in  apposition.  INIere  fissures  give  rise  to  no  deformity. 
The  recurrence  of  deformity,  when  external  restraining  forces  are  relaxed, 
is  a  characteristic  of  most  fractures,  serving  to  difi'erentiate  this  class  of 
injury  from  dislocation  of  joints.  In  estimating  the  degree  or  existence 
of  deformity,  previous  fractures  and  injuries,  periosteal  nodes,  exostoses, 
and  shortening  from  old  joint  inflammations,  or  contracted  tendons,  must 
be  eliminated.  Sprains  and  dislocations  often  give  distortions  similar  to 
fractures  near  corresponding  joints,  and  must  be  discriminated  by  other 
symptoms.  The  two  sides  of  the  body  should  always  be  compared  with 
the  bones  in  exactly  the  same  position.  Angular  and  rotary  displace- 
ment are  generally  easily  recognized  ;  but  shortening  due  to  overlapping 
is  often  difficult  to  verify,  because  accurate  measurement  is  almost  im- 
possible. The  bony  prominences  taken  as  standards  of  comparison  are 
rounded,  therefore  the  taj)e-measure  can  seldom  be  stretched  between 
exactly  corresponding  points.  Another  element  of  doubt  is  the  well- 
known  normal  inequality  in  length  of  bones  of  the  two  halves  of  the  body. 
Shortening  in  very  obli(jue  fractures,  as  of  the  thigh,  may  amount  to  sev- 
eral inches. 

A  clot  of  blood,  a  limited  condensation  by  cru.shing,  or  a  localized 
swelling  of  the  soft  tissues,  sometimes  simulates  deformity  from  displaced 
bone.  This  is  a  frequent  source  of  error  in  head  injuries.  A  long  needle 
thrust  through  the  skin  and  muscles  will,  by  impinging  on  the  hard  bony 
structure,  clear  up  this  uncertainty  in  some  cases.  In  fractures  involving 
joints  the  peculiar  deformity  due  to  the  synovial  sac  being  filled  with 
blood  or  inflammatory  products  may  aid  in  proving  the  existence  of  a 
fracture. 

Preternatural  mobility  after  injury  is  absolute  proof  of  a  fracture, 
except  in  those  rare  instances  where  dislocation  with  very  great  tearing  ol 
the  ligaments  allows  unusual  motion  at  a  joint.  Increased  mobility  is 
sought  for  by  endeavoring  to  move  one  part  of  the  bone  independently  of 
the  other,  and  so  to  jiroduce  angular,  rotary,  or  transverse  deformity  at 
the  seat  of  injury,  or  shortening  or  elongation  of  the  bone  or  entire  limb. 


FRACTUEES.  329 

The  best  method  of  developing  these  features  is  to  hold  one  extremity  of 
the  bone  immovable,  while  an  attempt  is  made  with  the  other  hand  to 
move  the  other  extremity.  If  preternatural  local  motion  can  be  obtained, 
and  it  is  usually  shown  by  the  production  of  the  deformities  mentioned, 
the  existence  of  fracture  is  undoubted.  Absence  of  mobility  must  not  be 
asserted  until  endeavors  have  been  successively  made  to  lengthen,  shorten, 
bend,  and  rotate  the  bone  at  the  seat  of  supposed  fracture,  because  some- 
times the  line  of  fracture  is  such  that  only  one  direction  of  force  will 
develop  the  abnormal  mobility. 

When  the  injury  is  near  a  joint  where  motion  is  a  normal  condition, 
when  the  bone  is  so  short  or  so  deeply  located  that  its  two  ends  cannot 
be  firmly  grasped,  and  when,  as  in  the  case  of  the  ribs,  sternum,  and 
fibula,  considerable  normal  elasticity  exists,  which,  upon  mani2:)ulation, 
can  simulate  mobility,  it  is  difficult  to  be  certain  that  preternatural 
motion  is  present.  Swelling  also  may  sometimes  prevent  a  just  apprecia- 
tion of  the  existence  of  mobility.  Fractures,  moreover,  may  exist  with 
little  or  no  increased  mobility  of  parts.  Such  is  the  case  in  impacted,  in 
partial,  and  in  interlocked  toothed  fractures.  When  one  of  two  parallel 
bones  is  broken,  the  mobility  is  often  slight.  When  the  shaft  of  a  bone 
is  broken  near  the  middle,  the  unnatural  seat  of  motion  may  be  sufficiently 
demonstrated  by  merely  placing  a  hand  under  the  limb  and  endeavoring 
to  lift  it  upon  this  single  point  of  support.  Motion  and  consequent  angular 
distortion  are  at  once  evident.  In  searching  for  motion  by  rotation  the 
fragment  moved  should  be  twisted  but  slightly,  since  the  muscles  may 
connect  the  fragments  sufficiently  closely  to  cause  the  rotation  to  be  trans- 
mitted to  the  fixed  fragment  when  any  considerable  degree  of  rotary 
movement  is  attempted. 

When  a  bone  is  intimately  associated  with  and  held  quite  fixed  by 
other  bones,  alternating  pressure  with  the  thumbs  or  fingers  applied  on 
each  side  of  the  point  of  injury  may  develop  motion.  This  method  is 
especially  applicable  to  the  fibula  and  the  ribs.  In  transverse  fractures 
motion  will  be  developed  best  by  force  applied  laterally,  and  in  oblique 
fractures  by  forces  tending  to  elongate  or  shorten  the  bone  in  the  direc- 
tion of  its  long  axis. 

Crepitus  is  the  grating  sensation  felt  by  the  surgeon  when  he  rubs  the 
rough  surfaces  of  the  broken  bone  together.  There  is  often  some  noise 
produced  by  this  manoeuvre,  but  the  diagnosis  rests  more  on  the  vibra- 
tions conducted  along  the  bone  to  the  hands  of  the  surgeon  than  on  any 
noise  appreciated  by  his  ears.  Mobility  and  grating  are  usually,  though 
not  always,  coexisting  symptoms.  Grating  cannot  be  felt  without  moving 
the  fragments,  but  motion  may  sometimes  be  produced  without  making 
any  grating  sensation  or  crepitus  perceptible.  The  development  of  crepi- 
tus requires  that  the  surfaces  should  be  rough,  and  that  they  should  be 
sufficiently  in  contact  to  render  friction  of  one  surface  upon  the  other 
possible.  If  the  ends  are  separated,  as  in  fracture  of  the  patella  ;  if  they 
greatly  overlap  so  that  the  smooth  surfaces  of  the  sides  of  the  bone  are  in 
contact ;  if  portions  of  muscle,  periosteum,  or  fascia  lie  between  the  pieces  ; 
or,  if  the  broken  surfaces  have  by  lapse  of  time  become  covered  with 
granulation  tissue,  the  surgeon  will  fail  to  observe  distinct  crepitus  until 
he  alters  these  conditions.  No  grating  is  possible  as  a  symptom  of  im- 
pacted or  green-stick  fracture  unless  the  parts  are  previously  rendered 
movable.  Sometimes  a  certain  manipulation  will  give  rise  to  distinct 
crepitus,  but  afterward  will  utterly  fail  to  produce  a  similar  result.    This 


330  DISEASES    AND    INJURIES    OF    BONES. 

is  because  by  reason  of  muscular  or  external  forces  a  different  relation  of 
the  fractured  surfaces  has  been  assumed  in  tlie  interval. 

To  elicit  grating  the  surgeon  manipulates  the  parts  in  such  a  manner 
as  to  produce  motion.  In  fact,  preternatural  mobility  and  crepitus  are 
demonstrable  at  the  same  time  and  in  a  similar  manner. 

When  possible,  it  is  best,  perhaps,  to  move  the  two  fragments  in  oppo- 
site directions,  as  this  gives  a  greater  degree  of  friction.  When  there  is 
much  overlapphig  extension  must  be  made  before  grating  can  be  felt. 
Placing  the  palm  of  one  of  the  hands  over  the  seat  of  injury  is  sometimes 
a  good  method  of  feeling  grating  in  bones  that  are  not  easily  grasped  with 
the  fingers.  Motion  is  then  obtained  by  the  other  hand  alone.  This  often 
avails  in  fracture  of  the  neck  of  the  femur  or  great  trochanter,  or  in  rib 
fractures.  In  the  last  the  proper  motion  may  at  times  only  be  obtained  by 
deep  inspiration  or  coughing.  If  the  limb  is  heavy,  an  assistant  may  steady 
or  move  one  portion  of  the  bone  while  the  surgeon  has  hold  of  the  other. 
In  most  cases  the  surgeon  is  able  to  control  both  parts  with  his  own  hands. 
When  the  presence  and  character  of  crepitus  have  once  demonstrated  the 
existence  of  fracture,  no  further  manipulations  should  be  attempted.  The 
character  of  grating  varies  with  the  character  of  the  fracture.  It  may  be 
a  single  slip  or  snap,  or  it  may  resemble  the  sensation  perceived  when  two 
pieces  of  roughened  dry  wood  are  rubbed  together  with  the  hands.  In 
greatly  comminuted  fractures  the  sensation  injparted  is  that  of  motion 
among  a  number  of  loose  pieces  of  hard  material.  If  any  sound  is  heard 
at  the  same  time  it  will  similarly  be  a  sharp  click,  a  dull,  muffled  scraping, 
or  an  irregular  crackling.  The  character  of  crepitus,  however,  will  not 
always  give  a  correct  idea  of  the  nature  of  the  fracture.  A  sensation  of 
loose  grating  may  be  felt  when  the  bones  are  held  closely  together.  The 
best  manner  of  conveniently  illustrating  the  peculiar  sensation  called 
crepitus  is  to  take  an  animal's  bone,  obtained  from  the  markets  or  else- 
where, and  after  wrapping  it  tightly  in  a  towel  to  break  it.  Motion  of 
the  fragments  in  various  directions  will  give  almost  typical  grating. 

Fracture  crepitus  may  be  confounded  with,  and,  therefore,  must  be  dis- 
tinguished from  the  friction-grating  of  diseased  joint  surfaces  and  that  of 
a  dislocated  bone  rubbing  on  the  periosteal  surface  of  another  bone.  It 
may  also  be  simulated  by  the  fine  crackling  of  inflamed  tendons  and 
bursse,  that  felt  and  heard  in  subcutaneous  emphysema,  due  to  puncture 
of  the  air-passages  or  decomposition  of  cellular  tissue,  pleuritic  or  pulmo- 
nary sounds,  and  the  crackling  of  coagulated  blood  in  the  tissues.  Joint 
grating  is  said  to  be  finer  and  moister  than  fracture  grating,  but  sometimes 
it  is  impossible  to  assert  with  positiveness  which  kind  of  crepitus  is 
present.  Those  conditions  giving  impressions  similar  to  fracture  crepitus 
can  usually  be  eliminated  by  collateral  evidence  if  the  surgeon  merely 
recollects  the  possibility  of  their  existence.  A  piece  of  necrotic  bone  may 
give  rise  to  sharp  grating  sensations  and  sounds,  if  in  a  position  where 
another  piece  of  bone  can  rub  against  it. 

A  curious  fallacy  is  this:  that  occasionally  the  crepitus  perceived 
appears  to  be  developed  in  a  certain  bone  when  it  is  really  due  to  fracture 
of  a  contiguous  part  of  the  skeleton.  Direct  auscultation  over  the  seat  of 
suspected  fracture,  either  with  or  without  a  stethoscope,  is  probably  of 
little  value,  because  the  sensation  of  rubbing,  rather  than  the  sound,  is 
the  important  diagnostic  feature.  Perhaps  auscultation  may  be  applicable 
and  serviceable  in  fractures  of  the  ribs  and  sternum. 

The  grating  produced  by  motion  of  the  fragments  is  frequently  per- 
ceptible to  the  patient.    Occasionally  a  giving-way  sensation,  accompanied 


FRACTUEES.  381 

by  a  sharp  crack,  is  noticed  by  the  patient  at  the  time  of  the  accident.  A 
similar  symptom  is  liable  to  occur,  however,  when  a  tendon  is  suddenly 
torn,  or  when  a  dislocation  with  great  ligamentous  laceration  takes  place. 
Hence,  this  snap,  even  when  noticed,  has  little  diagnostic  value.  It  is 
more  often  observed  by  the  patient  in  fractures  from  muscular  contraction 
than  from  violence. 

The  characteristic  symptoms  of  fracture,  then,  are  deformity,  preter- 
natural mobility,  and  crepitus.  Pain,  ecchymosis,  loss  of  function,  and  a 
variety  of  other  symptoms  may  be  present,  but  they  also  exist  in  such 
diverse  lesions  that  they  have,  as  a  rule,  no  diagnostic  value. 

A  persistent  tenderness  after  injury  limited  to  a  small  area  of  bone  is, 
however,  very  suggestive  of  fracture  without  displacement.  The  opinion 
of  the  laity,  that  pain  in  fractures  increases  when  the  fragments  of  bone 
are  becoming  united,  is  erroneous.  Painful  muscular  spasms,  due  chiefly 
to  irritation  of  the  muscles  by  the  sharp  points  of  the  broken  bone,  are 
frequently  experienced  in  the  early  stages  of  fractures. 

Swelling  deserves  little  recognition  as  a  symptom  of  fracture,  but  is  a 
factor  of  very  great  importance  in  the  determination  of  the  best  methods 
of  treatment.  When  the  inflammatory  swelling  is  rapid,  numerous  vesi- 
cles may  occur  on  the  surface.  These  may  be  filled  with  bloody  serum. 
It  is  well  not  to  rupture  them,  as  the  blood  is  often  absorbed  quite  rapidly. 
Intractable  ulceration  at  times  follows  if  the  epidermis  is  rubbed  off"  before 
new  epidermis  is  formed  beneath  that  which  is  pushed  up  by  the  fluid. 

Ecchymosis  about  the  seat  of  lesion  is  often  due  to  mere  contusion  of 
the  soft  parts.  If  it  first  appears  after  the  lapse  of  several  days,  and 
especially  if  the  black-and-blue  discoloration  is  found  at  some  distance 
from  the  seat  of  injury,  a  fracture  is  probably  present.  This  tardy  ap- 
pearance and  distant  location  are  due  to  the  difiiculty  which  the  blood 
extravasated  from  the  broken  bone,  periosteum,  and  marrow  has  in  reach- 
ing the  surface  through  the  fascial  layers.  This  slowly  occurring  ecchy- 
mosis, particularly  when  the  swelling  of  the  parts  results  in  the  formation 
of  blebs  on  the  surface,  may  be  mistaken  by  the  inexperienced  for  incipient 
gangrene.  Absorption  of  this  extravasation  from  the  deep  vessels  is 
always  effected  in  a  tardy  manner.  Indeed,  the  fracture  may  be  united 
before  all  the  discoloration  has  disappeared. 

Blood  extravasated  from  large  vessels  may,  it  is  said,  cause  synovitis 
by  coming  in  contact  with  the  outside  of  the  synovial  membrane.  It  is 
not  essential  that  the  synovial  sac  be  perforated  or  ruptured.  Rupture  of 
a  large  artery  as  a  complication  of  fracture  is  of  grave  import,  because  it 
gives  rise  to  great  extravasation  in  the  tissues. 

Loss  of  power  of  the  part  often  occurs  after  fracture,  sometimes  from 
fear  of  pain,  sometimes  from  loss  of  continuity  in  the  bony  lever.  This 
symptom  is  absent  in  many  cases  of  impacted,  serrated,  or  partial  frac- 
ture, and  also  in  those  in  which  the  periosteum  is  slightly  torn.  Patients 
have  walked  considerable  distances  with  a  fracture  of  the  femur  or  tibia. 
Motions  which  do  not  give  pain  at  the  seat  of  fracture,  and  which  do  not 
require  rigidity  of  the  particular  bone  that  is  broken,  can  be  perfectly 
performed  in  nearly  every  case.  Movement  of  the  fingers,  for  example, 
is  often  unimpaired  in  fracture  of  the  radius.  When  there  are  two 
parallel  bones,  one  may  serve  as  a  support  to  that  which  is  fractured,  and 
thus  prevent  impairment  of  its  ordinary  functions. 

Intermittent  muscular  spasms  are  often  an  annoying  symptom  of  frac- 
ture.    They  are  due  to  pricking  of  the  muscles  by  the  fragments,  and  to 


382  DISEASES    AND    INJURIES    OF    BONES. 

general  nervous  excitalnlity.     Numbness  and  other  nerve  symptoms  may 
be  present  from  coincident  injury  to  nerve  trunks. 

The  constitutional  symptoms  of  fracture,  after  the  period  of  shock,  are 
those  of  inflammation  and  its  consecjuences.  In  an  uncomplicated  closed 
fracture  there  are  scarcely  any  constitutional  symptoms.  A  slight  febrile 
rise  is  often  noticeable,  however,  durinjji:  the  first  three  days.  In  open 
fractures  suppuration  is  usual,  unless  care  is  taken  to  make  the  wound 
aseptic  immediately  after  its  receipt,  and  to  keep  it  so  durinir  cicatrization. 
Open  fractures,  managed  as  described,  are  usually  free  from  suppuration, 
and  cause  as  little  trouble  as  closed  fractures  of  similar  location  and 
extent.  Great  debility,  erysipelas,  tetanus,  fat  embolism,  septicaemia,  and 
pysemia  may  all  be  seen  as  setpiences  of  fractures  if  they  are  not  treated  so 
as  to  be  free  from  germ  infection.  In  old  age  fractures  may  prove  fatal 
from  the  consequent  debility  that  is  induced. 

Diagnosis. — The  symptoms  described  will  usually  render  the  diagnosis 
of  fracture  easy;  but  when  deformity,  preternatural  mobility,  and  grating 
are  not  all  found,  or,  if  found,  are  not  well  marked,  the  true  nature  of 
the  injury  may  be  obscure.  Especially  is  uncertainty  apt  to  arise  when 
the  lesion  is  near  a  joint,  for  here  there  is  a  great  deal  of  normal  mobility, 
and  joint-grating  may,  from  some  cause,  be  present.  Careful  examination 
under  ether,  with  the  corresponding  healthy  limb  uncovered  so  that  com- 
parison can  be  made,  will  usually  disclose  the  true  nature  of  the  lesion. 
Severe  bruises  can  be  discriminated  from  fractures  in  a  similar  manner. 

Dislocations,  because  of  the  resulting  deformity,  may  resemble  frac- 
tures near  joints,  but  in  dislocations,  unless  there  is  unusual  laceration  of 
ligaments,  the  normal  motions  of  the  articulation  are  impaired  ;  and  the 
surgeon  generally  finds  by  manipulation  that  a  sudden  and  abnormal 
check  to  free  movement  occurs  in  certain  positions  of  the  bont;s.  This  is 
not  the  case  in  fracture,  for  there  the  motion  is  almost  unlimited.  Again, 
in  dislocations  there  is  some  resistance  when  an  attempt  is  made  to  over- 
come the  deformity  by  putting  the  parts  in  position,  but  when  this  ha.-^ 
been  accomplished  there  is  little  tendency  to  recurrence  of  distortion.  In 
fractures,  on  the  other  hand,  the  deformity  is  remedied  with  ease,  but  the 
mere  weight  of  the  limb  or  a  slight  force  will  reproduce  it.  Voluntary 
motion  is,  as  a  rule,  not  so  impaired  in  dislocations  as  in  fracture,  for  the 
long  lever  is  intact,  and  there  is  simply  a  change  in  the  bearing-points  of 
the  articulation.  Fractures  have  an  appearance  or  "  physiognomy  "  of 
helplessness ;  dislocations  a  "  physiognomy "  of  rigidity.  The  normal 
relation  of  the  bony  prominences  about  a  joint  should  be  familiar  to  the 
surgeon,  so  that  any  deviation  by  dislocation  or  fracture  may  be  detected. 
The  various  "test-lines"  used  for  determining  these  relations  will  be 
spoken  of  in  discussing  fractures  near  special  joints. 

The  diagnosis  between  a  se})arated  epiphysis  and  a  fracture  in  the  same 
region  is  often  difficult ;  but  it  is  not  very  important,  since  the  treatment 
is  identical.  A  separated  epiphysis  gives  a  smoother  and  less  distinct 
grating  than  a  fracture,  and  is  apt  to  be  followed  by  diminished  growth 
in  length  of  the  bone. 

More  difficult  than  the  determination  of  the  simple  existence  of  fracture 
is  the  localization  of  the  exact  position  and  line  of  fracture.  This  is  often 
of  importance,  and  may  be  determinable  only  by  careful  fingering,  accu- 
rate measurements,  and  close  observation  of  changes  in  relative  position 
of  the  prominences.  Oftentimes  the  exact  line  of  break  is  only  to  be 
inferred. 

The  conduction  of  percussive  vibrations  from  one  end  of  a  bone  to  the 


FRACTURES.  333 

other  will  at  times  prove  the  non-existence  of  a  line  of  complete  fracture 
between  the  two  points.  Let  the  examiner  grasp  or  place  his  fingers  on  one 
extremity  of  the  bone,  and  then  give  the  other  several  quick,  sharp  blows 
with  his  finger-tips  or  a  small  hammer.  If  the  vibrations  are  distinctly 
conveyed  along  the  bone,  complete  or  impacted  fracture  is  improbable. 

Prognosis. — Closed  fractures,  if  uncomplicated,  usually  do  well.  Open 
fractures  are  more  serious  than  closed  fractures  of  a  similar  degree  of 
bone  injury,  only  when  infected  by  putrefactive  or  pyogenic  bacteria. 
Oblique  fractures  usually  leave  some  shortening  of  the  bone,  though  this 
may  be  very  slight  and  scarcely  noticeable.  Fractures  in  children  unite 
more  rapidly  than  those  in  adults ;  and  fractures  of  the  upper  more 
quickly  than  those  of  the  lower  extremity.  Small  bones  become  united 
sooner  than  large  ones.  Some  permanent  stiffiiess  is  the  rule  after  frac- 
tures involving  a  joint.  Many  fractures  will  be  followed  by  imperfect  or 
bad  results,  notwithstanding  the  best  surgical  treatment. 

It  is  a  common  mistake  to  suppose  that  when  the  bone  becomes  united 
the  patient  will  at  once  have  a  normal  limb.  Stiffness  of  the  articula- 
tions, a  dry  and  rough  skin,  oedema  and  congestion,  especially  when  the 
limb  hangs  down,  and  pain  aggravated  by  changes  in  the  weather  are  the 
most  frequent  sequelae  of  fracture.  Many  months  may  pass  before  they 
all  disappear.     Sometimes  one  or  more  of  these  symptoms  is  permanent. 

Stiffness,  when  not  due  to  actual  involvement  of  the  articulation  in  the 
line  of  fracture,  depends  on  the  simultaneous  occurrence  of  a  sprain, 
hemorrhagic  extravasation  around  or  into  the  synovial  sac,  the  entangle- 
ment of  tendons  in  the  ossifying  callus,  or  retraction  of  the  ligaments  and 
peri-articular  tissues  during  the  period  in  which  the  joint  was  kept 
immovable  by  the  fracture  dressing.  This  joint  stiffness  subsequent  to 
fractures  is  most  marked  and  more  persistent  in  old  persons  and  those  of 
a  rheumatic  diathesis. 

OEdema  results  from  pressure  of  the  fragments  or  callus  upon  the  deep 
veins,  or  from  phlebitis  and  coagulation  secondary  to  the  injury.  The 
coagula  formed  in  the  inflamed  veins  give  rise  in  very  rare  instances  to 
embolism.  Sudden  lividity  or  pallor,  dyspnoea,  precordial  pain,  and  death 
occurring  from  three  to  six  weeks  after  the  receipt  of  fracture  point  to 
venous  thrombosis  and  embolism.  Less  severe  symptoms  of  the  same 
character,  followed  by  localized  lung  consolidation  and  cough,  are  due  to 
detachment  of  a  smaller  embolus,  and  may  terminate  in  recovery.  If 
phlebitis  is  suspected,  it  is  wise  to  keep  the  patient  quiet  and  the  limb  at 
rest  until  absorption  of  the  internal  coagulum  has  occurred.  Its  frag- 
mentary detachment  from  the  walls  of  the  vein  is  to  be  feared. 

Cases  of  death  after  fracture  have  been  attributed  to  what  is  termed  fat 
embolism.  It  is  supposed  that  the  crushed  marrow  furnishes  free  fat 
globules,  which,  taken  up  by  the  veins  and  lymphatics,  produce  embolic 
plugging  of  the  luugs,  kidneys,  brain,  and  other  organs.  The  symptoms 
are  similar  to  those  of  shock^  and  of  the  venous  embolism  ;  but  occur 
later  than  the  former,  and  earlier  than  the  latter.  Xot  immediately  after 
injury,  as  are  symptoms  of  shock,  but  after  the  lapse  of  one  or  two  days 
have  symptoms  attributed  to  fat  embolism  been  observed. 

Death,  it  is  said,  may  occur  very  promptly  from  obstruction  of  the 
pulmonary  circulation  by  these  fat  emboli ;  or  it  may  be  delayed  for  a 
week  or  ten  days  and  be  due  to  inflammation  of  the  lungs,  brain,  or 
kidneys,  secondary  to  the  embolic  process.     Some  observers  suggest  that 

1  Hcilmes's  System  of  Surgery  :  Packard's  edition,  vol.  i.  f>P-  Ui  and  145. 


334  DISEASES    AND    INJURIES    OF    BONES. 

traumatic  delirium  and  liypostatic  pulmonary  congestion  after  fracture 
may  be  the  result  of  fat  embolism.  Experiments  show  that  disastrous 
results  are  only  liable  to  occur  when  very  extensive  fat  eml)olism  is 
present.  Otherwise  the  fat  is  eliminated,  perhaps  by  the  kidneys,  for  ftxt 
has  been  found  in  the  urine.  Si.il)jects  of  chronic  alcoholism  and  the  aged 
are  presumed  to  be  specially  liable  to  suffer  .severely  from  fat  embolism, 
because  the  weakened  heart  cannot  propel  the  fat  circulating  in  the  blood- 
current,  nor  are  the  damaged  viscera  able  to  resist  the  effects  of  the 
embolic  injury.     No  secondary  abscess  occurs  in  fat  embolism. 

The  indication  of  treatment  is  to  prevent  the  occurrence  of  fat  embo- 
lism by  keeping  the  crushed  limb  quiet  and  avoid  further  laceration  of  the 
marrow.  If  amputation  is  demanded  by  the  extent  of  the  injury,  it 
should  be  done  ])romptly  before  much  fat  is  absorbed.  Intravenous  injec- 
tion of  ether,  as  suggested  by  Packard,  may  perhaps  be  indicated. 

Fractures  may  be  complicated  with,  or  followed  by,  dislocation,  syno- 
vitis, gangrene,  caries,  necrosis,  injuries  to  viscera,  laceration  of  arteries, 
veins  or  nerves,  and  delirium.  These  circumstances  greatly  affect  the 
prognosis.  Whiskey-drinkers  and  the  aged  seem  especially  liable  to 
traumatic  delirium  after  fractures. 


Repair  of  Fractures. 

As  has  been  shown  is  the  section  on  healing  of  wounds,  repair  of  most 
soft  parts  results  in  a  cicatricial  tissue  which  is  analogous  to,  but  not 
identical  with,  the  structure  wounded.  In  bones,  however,  as  in  nerves, 
a  much  more  perfect  regeneration  occurs.  Indeed,  the  uniting  bone,  if 
examined  sufficiently  long  after  the  time  of  fracture,  has  the  microscopic 
structure  of  true  bone. 

Bones  are  repaired  by  the  same  general  processes  as  are  other  tissues. 
The  cells  of  the  periosteum  and  marrow,  and  those  lining  the  Haversian 
canals  and  the  lacun?e  of  the  bone  multiply.  By  this  proliferation  is 
formed  a  mass  of  granulation  tissue,  which  fills  the  spaces  between  the 
pieces  of  bone  and  sometimes  infiltrates  the  parts  around  the  bone.  This 
new  material  gradually  becomes  ossified  by  the  deposition  of  earthy 
salts  at  numerous  points,  and  the  subsequent  coalescence  of  these  ossific 
centres.  The  time  after  fracture  at  which  bony  particles  are  first  formed 
in  the  bond  of  union  is  probably  two  or  three  weeks.  The  transition 
from  granulation  tissue  to  bone  is  usually  through  the  connective  tissue 
stage ;  though  occasionally  the  granulation  material,  at  least  in  some 
parts,  becomes  cartilage  before  it  is  transformed  into  bone.  Some  of  this 
new  bone,  which  is  at  first  spongy  in  structure,  becomes  compact ;  some 
of  it  becomes  more  rarefied,  and  some  is  entirely  absorbed  ;  until,  finally, 
if  the  fragments  have  been  kept  in  correct  apposition,  the  bone  is  so  well 
restored  to  its  normal  condition  that,  even  when  the  dried  bone  is  sawn 
open,  no  line  of  fracture  can  with  certainty  be  distinguished.  In  fact,  the 
changes  occurring  in  repair  of  fractures  differ  only  in  a  degree  from  those 
observed  in  the  normal  growth  of  bone.  The  location  and  degree  of  in- 
jury and  the  relative  position  of  the  fragments  modify  the  number  of 
Nature's  resources,  and  change  the  character  and  amount  of  the  repara- 
tive work  to  be  done.  Hence  must  be  described  more  minutely  the 
various  steps  of  repair  in  closed,  in  open,  and  in  epiphyseal  fractures; 
and  under  closed  fractures  the  differences  between  fractures  of  the  shafts 


REPAIR    OF    FRACTURES.  335 

of  long  bones  or  portions  of  bone  with  a  medullary  canal,  and  fractures 
running  into  joints. 

After  the  shaft  of  bone  is  fractured  the  periosteum,  torn  and  stripped 
up  from  the  bone  though  it  may  be,  often  forms  a  sort  of  ragged  sheath 
around  the  seat  of  fracture.  Within  the  limits  of  this  imperfect  perios- 
teal sheath  new  tissue  to  unite  the  bone  is  principally  deposited.  The 
periosteum,  the  injured  marrow,  and  the  broken  cylinder  of  compact  bene 
all  become  inflamed  and  furnish  cellular  elements,  which,  mingling  with 
the  blood-clots  and  effused  serum,  form  an  inflammatory  exudate  which 
becomes  granulation  tissue. 

The  bone  is  the  least  active  and  slowest  in  furnishing  new  tissue, 
because  it  normally  has  fewer  cells  of  its  own  than  the  marrow  and  peri- 
osteum, but  at  length  granulations  appear  on  the  ends  of  the  fragments 
and  finally  coalesce  across  the  gap.  This  granulation  tissue  filling  up 
the  space  between  the  ends  of  the  fragments  and  lying  within  the  confines 
of  the  periosteum  and  other  tissues  surrounding  the  seat  of  fracture,  has 
of  course  no  firmness  until  ossification  begins.  When  it  begins  to  be  firm 
it  is  called  callus.  During  this  early  period  of  repair  the  connective  tissue 
in  the  structures  outside  of  the  periosteum  is  also  filled  with  proliferating 
cells,  and  thus  steadies  the  broken  bone  by  glueing  the  adjacent  muscles, 
tendons,  and  fascias  together. 

The  granulation  tissue  formed  usually  ossifies  in  man  as  connective  tissue 
without  showing  any  cartilaginous  stage ;  but  when  fractures  in  man  are 
kept  perfectly  at  rest  the  granulation  tissue  which  lies  between  the  frag- 
ments and  around  the  bone  may  become  cartilaginous  before  being  ossified. 
In  any  event  it  requires  weeks  for  the  callus  to  gain  the  hardness  of  bone. 
Ossification  through  the  cartilaginous  stage  is  the  common  event  in  the 
lower  animals. 

During  this  period  the  marrow  callus,  which  has  occluded  the  medullary 
canal  like  a  plug,  and  the  external  callus  have  held  the  fragments  firmly  in 
position.  These  depositions  go  by  the  name  of  provisional  or  temporary 
callus.  As  the  interosseous  callus — ^that  is,  the  callus  between  the  two 
cylinders  of  bone,  called  the  permanent  or  definitive  callus — becomes  hard, 
the  external  callus,  as  well  as  the  internal  callus  which  lies  in  the  medul- 
lary canal,  is  absorbed.  Thus  the  surface  of  the  bone  is  finally  given  its 
normal  contour,  and  the  medullary  canal,  which  had  been  completely 
filled  up  in  both  fragments  for  some  distance  from  the  break,  is  reestab- 
lished. 

Small  pieces  of  comminuted  bone  may  be  imbedded  in  the  callus  and 
assist  in  increasing  its  bulk.  These  fragments,  even  if  entirely  denuded 
of  periosteum,  do  not  die,  unless  the  fracture  is  infected  with  pyogenic 
germs  or  other  septic  organisms.  Sometimes  such  pieces  become  necrotic 
and  remain  in  the  callus  as  foreign  bodies,  giving  little  trouble ;  though 
they  are  apt  to  cause  prolonged  irritation  and  interfere  with  union. 

If  there  is  much  displacement  union  is  efiected  between  the  nearest 
lateral  surfaces  of  the  bone,  the  open  medullary  cavity  is  covered  in  by 
new  osseous  structure,  and  the  displaced  ends  of  the  fragments  become 
round  and  smooth  as  in  a  stump  left  after  an  amputation. 

Fractures  of  short  and  flat  bones  and  of  the  ends  of  long  bones  are 
not  accompanied  by  injury  of  marrow  in  a  medullary  canal.  The  pro- 
cess of  union  is,  with  the  exceptions  due  to  this  fact,  identical  with  that 
in  the  shaft  of  long  bones.  Unless  there  be  much  motion  during  the 
time  of  union,  very  little  callus  is  found  around  the  seat  of  fracture,  and, 
therefore,  the  prominent  oval  mass  felt  in  the  form  of  fracture  just  de- 


83G  DISEASES    AND    INJURIES    OF    BONES. 

scribed  is  absent.  This  absence  is  probably  due  to  the  fact  that  the  peri- 
osteum in  these  locations  is  less  easily  stripped  up  by  the  injury.  Less 
laceration  and  less  displacement  therefore  occur.  Union  is  favored,  more- 
over, by  the  broad  surfaces  of  spongy  and  vascular  bone  which  are  in 
contact  and  by  the  less  liability  to  motion  from  involuntary  muscular 
spasms.  Hence  less  callus  is  formed,  for  a  large  amount  of  callus  usually 
means  difficult  repair  because  of  great  displacement  or  much  motion. 

When  the  line  of  fracture  invades  the  articular  surface  of  a  bone  the 
deposition  of  callus  differs  from  that  described  in  fractures  not  involving 
a  joint.  The  bony  surface  covered  with  cartilage  and  bathed  in  synovial 
fluid  does  not  usually  furnish  granulation  tissue  and  callus  as  do  the  parts 
of  the  bone  which  are  covered  with  periosteum  and  surrounded  by  nuis- 
cles  and  fascias.  Hence  when  union  occurs  it  is  by  calkis  furnished  by 
the  envelope  of  the  extra-articular  portion  of  the  bone  and  by  the  fracture 
surfaces  themselves.  There  is  no  ensheathing  callus  on  the  articular  sur- 
face to  aid  in  repairing  the  edge  of  the  fracture  there. 

The  articular  cartilage  which  is  split  by  the  same  line  of  fracture  does 
not  unite ;  or  if  so  the  normal  structure  is  replaced  by  cicatricial  fibrous 
tissue  only.  As  a  result  there  is  shown  on  the  joint  surface  a  groove  in 
the  cartilage  or  a  line  of  uncovered  bone  to  mark  the  position  of  the 
former  fracture.  Sometimes  in  injuries  of  this  sort,  as  for  example  in  frac- 
ture of  the  patella,  where  correct  apposition  has  not  been  obtained,  the  bond 
of  union  is  very  imperfect,  being  mostly  fibrous  instead  of  osseous. 

Open  fractures,  if  aseptic,  unite  in  a  manner  identical  with  that  which 
has  been  described  in  chased  fractures.  If  supi)uration  occurs,  the  repair 
is  glower,  because  the  warfare  between  the  cells  and  the  microorganisms  is 
followed  by  deatii  of  much  new  tissue  as  well  as  destruction  of  the  sur- 
rounding bone,  muscle,  and  fascia.  Violent  inflammation  of  a  mycotic 
kind  is  added,  therefore,  to  the  simple  traumatic  inflammation  of  aseptic 
fractures.  Repair,  therefore,  is  antagonized,  and  open  fractures,  unle.ss 
they  ai'e  early  converted  into  closed  fractures  by  i)rimary  healing  of  the 
soft  parts  next  the  bone,  require  a  long  time  to  unite.  Superficial  areas 
of  bone  or  detached  splinters  may  become  necrotic  and  greatly  retard 
healing  of  the  soft  parts  and  union  of  the  main  fragments.  If  much  bone 
is  lost  by  necrosis  or  by  the  shattering  force  causing  fracture,  bony  union 
across  the  wide  gap  may  be  impossible,  because  the  ossific  influence  is 
not  great  enough.     Fibrous  union  then  occurs. 

Epiphyseal  separations,  or  fractures,  seem  to  unite  as  readily  as  true 
fractures.  The  union  is  said  to  be  at  once  a  bony  one  instead  of  by  the 
normal  epiphyseal  cartilage  as  previously.  The  growth  in  length  of  the 
bone  is  retarded  by  this  precocious  union  between  the  shaft  and  epiphysis. 
Agnew  thinks  that  in  some  cases  the  epiphyseal  cartilage  at  the  other  end 
of  the  bone  acts  in  a  compensatory  manner  by  allowing  an  unusual  length- 
ening there.  Very  little  is  known  of  the  peculiarities  of  union  in  this 
form  of  injury. 

Fractures  of  cartilages,  such  as  the  costal  and  laryngeal,  which  tend  t(' 
ossify  with  advancing  age,  unite  as  bones  by  a  material  resembling  callus. 

Trf:atment. — The  essential  points  in  the  treatment  of  fractures  are  the 
replacing  of  the  displaced  fragments  as  soon  as  possible,  the  prevention  of 
recurrence  of  displacement,  attention  to  the  condition  of  the  soft  parts 
around  the  seat  of  fracture,  and  due  consideration  of  the  patient's  general 
health.  The  surgeon's  object  is  to  obtain  prompt  union  with  as  little 
deformity  as  possible.  At  times,  unfortunately,  more  or  less  deformity  is 
unavoidable,  because  of  the  situation  and  direction  of  the  line  of  fractui'e. 


EEPAIR    OF    FRACTURES.  337 

Every  effort  should  be  made,  however,  to  make  this  as  slight  as  pos- 
sible. 

After  receiving  a  fracture  of  the  upper  extremity  the  patient  can  usually 
walk  to  the  place  of  treatment  if  the  injured  limb  is  supported  by  his 
other  hand  or  a  sling.  If  the  lower  extremity  is  the  seat  of  suspected  frac- 
ture, walking  should  be  prohibited,  and  the  patient  carried  by  four  men 
on  a  stretcher,  settee,  or  wide  board.  It  is  recommended  by  some  writers 
that  these  carriers  should  not  keep  step,  because  so  doing  has,  it  is  said,  a 
tendency  to  impart  a  painful  swinging  motion  to  the  litter.  Other  writers 
advise  them  to  step  simultaneously.  It  matters  little  which  precept  is 
followed  if  the  litter  is  held  steadily  and- given  no  sudden,  jars;  especially 
is  this  so  if  the  patient  lies  immobile  and  does  not  try  to  move  his  body 
and  limbs  so  as  to  neutralize  the  vibratory  movements  of  the  stretcher. 

The  patient  must  be  carried  in  severe  fractures  of  the  upper  limbs  also 
if  shock  is  great.  A  crude  splint  of  board,  twigs,  straw,  pasteboard,  or 
any  other  material  of  sufficient  rigidity,  to  steady  the  fragments  during 
transportation  should  be  bound  to  the  limb.  This  may  be  done  outside 
the  clothing.  In  fractures  of  the  leg  or  thigh  the  opposite  limb  makes  a 
good  sjDlint  to  which  to  bind  ternporarily  the  broken  one.  Hay,  rags,  or 
small  pillows  may  be  placed  between  the  limbs  before  they  are  tied 
together. 

The  bed  for  the  permanent  treatment  of  a  patient  with  a  fracture  of  a 
leg  or  thigh  should  preferably  be  a  narrow  one,  so  that  the  attendants  can 
conveniently  reach  each  side  of  his  body.  A  firm  mattress  that  will  not 
sag  down  under  the  buttocks  is  necessary.  One  made  of  hair  and  laid 
upon  slats  or  woven  wire  is  probably  the  best.  The  old-fashioned  sacking 
bottom  for  supporting  the  mattress  is  undesirable.  Patients  accustomed 
to  sleeping  upon  feather  beds  may  be  very  uncomfortable  unless  they  have 
softer  mattresses  than  hair.  In  such  cases  a  thin  feather  bed  may  be 
used  if  it  is  thoroughly  supported  by  the  framew-ork  beneath  it.  Good 
springs  under  a  hair  mattress  are  not  objectionable  if  they  do  not  permit 
the  upper  surface  of  the  mattress  to  become  uneven.  There  is  no  neces- 
sity for  a  specially  made  fracture-bed,  if  the  bed-pan  and  urinal  are  care- 
fully and  intelligently  placed  when  the  contents  of  the  rectum  and  bladder 
are  to  be  voided.  The  sheet  under  the  patient  should  be  kept  smooth  ; 
its  edges  may  be  tacked  or  tied  to  the  sides  of  the  bed.  When  a  clean 
sheet  is  to  be  put  under  him  it  should  first  be  folded  or  rolled  up  longitu- 
dinally for  half  its  width.  This  doubled-up  portion  is  to  be  carefully 
pushed  under  the  right  side  of  the  patient  while  he  is  very  slightly  turned 
on  his  left  side ;  then  he  is  to  be  carefully  turned  on  his  back  and  slightly 
on  his  right  side  until  a  second  person  standing  on  the  left  side  of  the  bed 
draws  from  under  him  the  folded-up  edge  of  the  sheet.  Very  little  move- 
ment of  the  patient  is  made  when  this  method  is  adopted. 

During  long  confinements  to  bed  the  sacrum,  heels,  and  other  points  sub- 
jected to  pressure  should  be  washed  frequently  with  equal  parts  of  alcohol 
and  water,  and  every  precaution  taken  to  avoid  the  occurrence  of  bed- 
sores. Air  mattresses  may  be  demanded  on  this  account  in  cases  of  frac- 
ture of  the  spinal  column,  where  the  accompanying  paralysis  greatly  in- 
creases the  tendency  to  bedsores. 

Replacing  the  fragments  in  their  normal  relation,  technically  called 
reduction  or  "  setting,"  should  be  attempted  as  soon  as  the  patient  has 
been  conveyed  to  a  convenient  place.  Early  reduction — that  is,  reduction 
before  the  advent  of  inflammatory  swelling— is  nearly  always  demanded. 
It  is  less  painful  to  the  patient,  and  adjustment  can  thereby  be  more  easily 

22 


338  DISEASES    AND    INJURIES    OF^    BONES. 

and  accurately  accomplished  than  it"  the  necessary  niani})iilations  are  de- 
laved.  Moreover,  the  subsecjuent  inflammation  and  chronic  muscular 
spasms  will  probably  be  les.s  severe  if  the  sharp  points  of  displaced  bone 
are  prevented  by  reduction  from  continually  irritating  and  wounding  the 
soft  tissues.  When  the  case  has  not  been  seen  until  severe  inflammatory 
action  has  stiffened  the  muscles  and  greatly  distended  the  fascias  and  in- 
tegument by  interstitial  swelling,  it'may  at  times  be  proper  to  delay  reduc- 
tion until  this  condition  has  been  relieved.  Absolute  rest  of  the  part  with 
the  fragments  in  moderately  good  position  should  be  adopted  and  accom- 
panied, perhaps,  by  antiphlogistic  local  treatment,  and  sometimes  even  by 
incision  through  the  constricting  skin  or  fascia.  After  the  lapse  of  a  few 
days  accurate  reduction  may  be  effected.  The  manipulations  necessary 
for  accurate  adjustment,  if  made  when  the  liml)  was  stiff  and  so  swollen, 
might  cause  rupture  of  vessels  or  nerves,  or  by  increasing  the  internal 
pressure  lead  to  gangrene.  It  may  be  judicious,  perhaps,  to  delay  also 
when  there  is  evidence  that  the  })riucipal  artery  or  nerve  has  been  torn  by 
the  original  injury,  because  the  consequent  gangrene  might  be  attributed 
by  a  court  and  jury  to  the  early  manipulations  made  for  reduction. 

As  a  rule,  however,  fractures  are  to  be  reduced  and  dressed  imme- 
diatelv  ;  and  only  in  exceptional  instances  should  the  surgeon  be  deterred 
from  attempting  accurate  adjustment. 

When  subcutaneous  hemorrhage  or  inflammatory  swelling  endangers 
the  safety  of  the  limb  by  arresting  circulation,  as  shown  by  coldness  and 
numbness  of  the  fingers  or  toes,  free  incisions  should  be  made  through 
the  tense  integument  to  permit  the  fluids  to  drain  away  and  thus  relieve 
the  pressure  upon  the  vessels  and  nerves.  Great  stress  is  laid  upon  this 
measure,  as  threatening  gangrene  may  often  be  averted  by  several 
cutaneous  incisions  of  two,  three,  or  four  inches  in  length. 

Reduction  of  displacement  should  be  attempted  even  if  the  case  is  first 
seen  several  days  or  weeks  afler  injury.*  More  force  will  he  recpiired 
under  such  circumstances  ;  but  of  this  more  will  be  said  under  the  dis- 
cussion of  Refracture  of  Deformed  or  Vicious  Union  of  Fractures. 

Reduction  is  sometimes  readily  effected  by  merely  rela.xing  the  muscles 
tending  to  cause  displacement,  whereupon  the  fragments  fall  into  place. 
At  other  times  some  additional  pressure  and  manipulation  with  the  fingers 
are  necessary  before  the  more  or  less  numerous  pieces  of  bone  are  pressed 
into  correct  apposition.  In  still  other  cases  an  extending  force  must  be 
applied  to  the  limb  on  the  distal  side  of  the  fracture,  while  counter-ex- 
tension is  exerted  upon  the  other  side  of  the  seat  of  injury.  By  counter- 
extension  I  mean  a  resistance  to  the  extending  force  so  that  the  body  will 
not  be  pulled  in  the  direction  of  the  force  used  to  make  traction  on  the 
overlapping  fragments.  Extension  and  counter-extension  are  to  be  made 
by  grasping  the  limb  above  and  below  the  fracture,  and  pulling  with 
one  hand  while  the  other  resists  or  pulls  in  the  opposite  direction.  In 
dealing  with  a  large,  heavy  limb  it  may  be  necessary  for  the  counter- 
extension  and  sometimes  the  extension  also  to  be  made  by  an  assistant. 
Such  duties  are  also  entrusted  to  assistants  when  the  surgeon  needs  his 
fingers  to  mould  the  fragments  into  position.  Elxtension-traction  should 
be  steady,  continuous  and  moderate,  and  exerted  in  the  axis  of  the  limb. 
No  greater  force  than  can  be  obtained  by  the  firm  grasp  and  strength  of 
the  surgeon  or  assistants  should  be  applied  to  the  reduction  of  a  recent 
fracture.  Pulleys  are  never  justifiable.  What  is  required  is  a  firm, 
steady  pull  of  moderate  force  that  will  tire  out  the  contracted  muscles. 
Anaesthesia  is  often  desirable,  as  it  relaxes  spasm  and  prevents  pain.     In 


REPAIR    OF    FRACTURES.  339 

many  cases  ether  has  already  been  given  to  enable  the  surgeon  to  make  a 
careful  examination,  therefore  the  reduction  is  at  once  effected  and  the 
fracture  dressing  applied  before  consciousness  is  regained.  Extension 
overcomes  shortening  due  to  overlapping  of  fragments,  but  if  there  is 
lateral  and  rotary  displacement,  coaptation  with  the  fingers  and  rotation 
of  the  limb  should  be  added  to  the  extension.  These  combined  manipu- 
lations will  usually  correct  the  deformity.  In  impacted  fractures  and  in 
open  fractures  with  one  fragment  thrust  through  the  integument,  as 
through  a  button-hole,  much  difficulty  may  be  found. 

When  a  portion  of  bone  into  which  a  muscle  is  inserted  is  broken  off 
it  is  to  be  put  and  held  iu  position  by  traction  exerted  against  the  muscle. 
Fractures  of  the  olecranon  and  patella  illustrate  this  point. 

Sometimes  difficulty  is  experienced  in  properly  and  completely  reduc- 
ing the  fragments.  This  may  be  due  to  impaction,  to  a  fragment  being 
entangled  in  or  thrust  through  muscles  or  fascias,  to  one  fragment  being 
locked  behind  another  and  held  there  by  muscular  tension,  or  to  actual 
crushing  and  powdering  of  portions  of  spongy  bone.  Inability  to  obtain 
a  firm  hold  on  one  fragment  may  also  be  a  cause  of  imperfect  reduction. 
If  muscles  or  fascias  prevent  reduction,  subcutaneous  section  with  a  teno- 
tome is  justifiable  to  prevent  permanent  deformity  from  this  cause. 

An  incision  of  skin  and  muscles  is  not  infrequently  required  in  open 
fractures  before  reduction  can  be  obtained  and  also  to  permit  thorough 
disinfection  of  the  wound  cavity  and  to  make  provision  for  free  drainage. 
Whenever  replacement  is  difficult,  an  endeavor  should  be  made  to  replace 
the  fragments  along  a  course  the  exact  reverse  of  that  which  was  given 
by  the  vulnerating  force.  The  portion  of  displaced  bone  should  retrace 
the  steps  by  which  it  reached  its  abnormal  position. 

After  reduction  has  been  obtained  the  limb  should  be  compared  with 
the  sound  side,  and  the  test  lines  verified,  to  establish  the  correctness  of 
the  replacement.  Swelling  may  make  appearances  deceptive.  Great  care 
in  this  respect  is  necessary  in  fractures  near  joints.  Continuous  extension 
by  means  of  weights  is  often  employed  to  overcome  overlapping.  It  acts 
by  gradually  tiring  out  the  displacing  muscles,  and  thus  effecting  reduc- 
tion.    It  is  the  usual  method  in  fractures  of  the  femur. 

Closed  fractures  seldom  require  any  lotions  or  other  external  medicinal 
applications.  Lead-water  and  laudanum  and  similar  remedies,  applied 
to  the  skin,  can  avail  little  in  relieving  inflammation  of  broken  bones 
and  torn  muscle.  Immobility  and  freedom  from  muscular  spasm  are 
therapeutic  agents  of  far  more  value  than  external  lotions. 

After  reduction  has  been  satisfactorily  accomplished,  displacements  may 
recur  through  the  action  of  gravity,  njuscular  contraction,  or  restlessness 
of  the  patient.  The  surgeon  must  guard  against  such  recurrence  by 
applying  some  form  of  fracture  dressing,  which  will  retain  the  fragments  in 
proper  position.  The  best  form  of  dressing  will  be  that  which  corrects 
the  tendency  to  displacement  in  the  individual  case,  and,  at  the  same  time, 
steadies  and  immobilizes  the  limb.  The  special  tendency  to  displacement 
varies  in  each  case  with  the  line  and  position  of  fracture,  and  should  be 
recognized  before  the  form  of  dressing  is  decided  upon. 

There  are  occasions  in  which  no  retention  apparatus  is  needed,  but  these 
instances  are  rare.  The  confidence  of  the  patient  and  greater  safety 
against  displacement  are  obtainable  by  adopting  some  mode  of  fracture 
dressing. 

Fracture  dressings  may  be  grouped  under  three  heads  :  ( 1)  Those  which 
give  moderate  continuous  traction,  or  maintain  extension  which  was  applied 


340  DISEASES    AND    INJURIES    OF    BONES. 

when  tlie  fracture  was  first  adjusted  ;  (2)  those  whicli,  by  virtue  of  their 
rigidity  or  fixedness,  resist  retraction  ;  (3)  those  which,  by  virtue  of  their 
inflexibility,  prevent  auguhir  or  lateral  displacement  by  giving  lateral 
support  to  the  fracture.  These  forms  may  be  combined  in  the  treatment 
of  a  given  fracture.  The  simplest  apparatus  is  the  best.  The  articles 
employed  in  dressing  fractures  are:  roller  bandages;  padding,  such  as 
cotton  or  oakum  ;  adhesive  i)laster  ;  splints  of  any  rigid  material,  such  as 
wood,  felt,  pasteboard  ;  cotton  fabrics  stiffened  with  gy|)sum,  silicate  of 
sodium,  or  starch;  fracture  boxes;  and  weights  for  making  continuous 
traction.  As  a  rule,  no  roller  bandage  should  be  applied  immediately  to 
the  lind)  under  the  splint,  for  the  inelastic  constriction  thus  made  may 
lead  to  gangrene,  if  unexpected  inflammatory  swelling  occur,  and  is,  at 
auy  rate,  of  no  service.  Bandaging  of  the  distal  portion  of  the  limb, 
beyond  the  splint,  tends  to  prevent  oedema  there  ;  which  is  often  seen, 
because  the  fracture  dressing,  even  when  properly  applied,  interferes 
somewhat  with  venous  return.  It  is  usually  preferable  not  to  bandage 
even  this  portion  of  the  limb. 

The  wdema,  unless  excessive  or  accompanied  by  discomfort,  is  of  no 
importance.  In  dressing  fractures  of  the  shaft  of  bones,  the  nearest  joint 
above  and  that  below  should,  as  a  rule,  be  made  immovable  by  the  splint, 
because  motion  allowed  at  such  articulations  may  cause  displacement  of  the 
approximated  fragments.  Splints,  if  not  moulded  to  the  patient's  person, 
should  be  padded  with  a  thin  layer  of  cotton-wadding,  so  as  to  make 
equable  and  elastic  pressure,  and  thus  accurately  conform  to  the  contour 
of  the  limb.  A  board  slipped  into  a  long  bag, afterward  smoothly  stuffed 
with  cotton,  makes  a  good  splint. 

The  splints  after  adjustment  are  to  be  held  in  place  by  spiral  or  reverse 
turns  of  a  roller  bandage,  applied  with  sufficient  firmness  to  maintain  the 
apparatus  in  position,  and  thus  make  the  limb  rigid  so  that  no  motion  can 
occur  at  the  seat  of  fracture.  The  fingers  or  toes  should  usually  be  left 
uncovered  that  lividity,  coolness,  or  oedema,  due  to  improper  constriction, 
may  be  noticed.  The  turns  of  the  bandage  can  be  kept  from  slipping  by 
painting  a  broad  line  of  mucilage  or  silicate  of  sodium  down  the  outside  of 
the  completed  dressing,  or  by  applying  a  narrow  strip  of  adhesive  plaster 
down  its  exterior  so  as  to  hold  the  folds  of  the  bandage.  Another  method 
is  to  stitch  the  bandage  to  the  covering  of  the  splint.  Before  applying 
the  fracture  apparatus,  the  skin  should  be  washed  with  soap  and  water 
and  shaved.  In  open  fractures  this  is  exceedingly  important.  Anti- 
septic lotions  are  to  be  used  in  these  cases  freely,  to  destroy  any  germs  which 
may  have  gained  access  to  the  wound.  Sublimate  (1  :  500  or  1  :  1000) 
solution  is  probably  the  best ;  and  can  subse([uently  be  washed  out  of  the 
wound  by  a  weaker  solution.  All  recesses  must  be  made  asej)tic,  and 
drainage  tubes  used  to  drain  all  dangerous  pockets.  Counter-incisions 
are  often  demanded,  and  all  devitalized  parts  .should  be  trimmed  away. 
In  truth,  the  wound  must  be  treated  and  dre.s.sed  exactly  as  any  other 
lacerated  infected  wound,  and  then  have  fracture  appliances  adjusted. 
Conformable  splints  of  metal,  felt  or  pasteboard,  or  moulded  splints,  such 
as  will  be  described  below,  are  far  better  than  any  form  of  carved 
wooden  splint.  A  thin  board  may  be  made  flexible  transversely  by  cut- 
ting six  or  eight  parallel  longitudinal  incisions  in  it,  extending  almost, 
but  not  entirely,  through  its  thickness.  A  sheet  of  rubber  adhesive-plaster 
may  then  be  smoothly  fastened  over  the  uncut  side,  in  order  to  strengthen 
the  hinges  made  at  the  incisions  when  the  board  is  bent. 


REPAIR    OF    FRACTURES. 


341 


Fig.  148. 


Moulded  splints  are  a  most  desirable  form.  They  are  at  first  suffi- 
ciently soft  to  be  accurately  fitted  to  the  inequalities  of  the  limb,  but 
subsequently  become  hard.  Felt,  gutta- 
percha, and  pasteboard  may  be  thus 
moulded  after  being  made  soft  by  heat 
or  moisture.  Strips  of  gauze  or  any 
woven  fabric  with  wide  meshes  can  be 
converted  into  excellent  splints  by 
saturating  them  with  a  watery  mixture 
of  gypsum,  the  so-called  plaster-of-Paris. 
Ten  to  twelve  of  these  pasty  strips,  one 
over  the  other,  are  applied  to  the  limb 
while  it  is  held  in  proper  position.  They 
soon  become  rigid  by  the  "  setting  "  or 
hardening  of  the  gypsum.  Lateral  or 
anterior  and  posterior  splints  of  any 
shape  may  thus  be  made  and  held  in 
position  by  roller  bandages.  If  it  is  pre- 
ferred, the  limb  may  be  encased  in 
sheets  or  bandages  of  gauze  saturated 
with  gypsum.  This  method  is  that  used 
in  making  the  so-called  immovable 
dressings,  which  are  often  very  valuable 
after  the  primary  inflammation  of  in- 
jury has  subsided.  These  hardened 
encasements,  if  made  with  silicate  of 
sodium,  glue,  or  any  material  with  some 
elasticity  may  be  split  open  on  one  side, 
so  that  they  can  be  sprung  open,  some- 
what as  a  book,  and  thus  become  mov- 
able splints.  They  may  be  furnished  with  eyelets,  and  thus  laced  like  a 
shoe  when  reapplied. 

The  gypsum  powder  for  this  purpose  must  be  kept  dry,  for,  if  it  absorbs 
moisture,  it  will  not  "  set."  It  may  be  mixed  with  enough  water  to  make 
a  paste  of  the  consistence  of  cream,  which  is  rubbed  into  the  gauze  at  the 
time  of  dressing  the  fracture,  or  the  dry  powder  may  first  be  rubbed  into 
the  meshes  of  the  gauze  and  the  gauze  strips  or  bandages  dipped  into 
water  as  needed.  If  gypsum  gauze  is  not  used  at  once,  it  should  be  pre- 
served in  a  dry  place.  The  setting  can  be  retarded  by  the  addition  of  a 
little  dissolved  glue,  of  borax,  or  cream  of  tartar  to  the  water,  and 
hastened  by  using  hot  water  or  adding  salt.  A  little  skill  in  cutting  out 
Y-shaped  pieces  of  the  sheets  of  gauze,  and  in  overlapping  the  edges  thus 
made  when  corners  are  to  be  turned,  will  enable  the  surgeon  to  make 
moulded  splints  to  suit  fractures  in  all  regions.  Such  splints  may  be 
varnished  to  prevent  absorption  of  fluids,  and  strengthened  by  incorpor- 
ating strips  of  zinc  between  the  layers.  In  open  fractures  which  have 
become  infected,  and  are  therefore  suppurating,  openings  may  be  made 
in  the  splints,  so  that  the  wound  may  be  dressed  without  displacing  the 
fracture  apparatus.  Strips  of  metal  to  strengthen  the  dressings,  or  wire 
rings  for  suspension,  may  be  incorporated  within  the  layers. 

Reduction  of  overlapping  fragments  is  sometimes  best  accomplished  by 
continuous  traction  by  weights.  The  displacing  muscles  are  thus  tired 
out,  and  their  tendency  to  either  tonic  or  clonic  spasm  overcome.  The 
cord  carrying  the  weight  passes  over  a  pulley  and  is  attached  to  the  limb 


Posterior  gvp?um  splint  for  fracture  of 
the  leg.     (Stimson.) 


342 


DISEASES    AN1>    INJURIES    OF    BONES. 


by  strips  of  adhesive   pla-><ter.     The  tendency  t()  lateral  displacement  is 
then  obviated  by  coaptation  splints  at  the  seat  of  fracture.     This  method 


Fir.    ]-»;•. 


Anterior  aiul  posterior  gypsum  splints  witli  wire  rings  apj)lie<l  for  suspension  in 
fracture  of  leg.     (Stimsox.) 

is  most  employed  in  fractures  of  the  femur,  but  is  at  times  useful  else- 
where. 

It  is  a  safe  plan  always  to  remove  the  r'plints  within  twenty-four  hours 

Fig.  1.^0. 


Adhesive  plaster  and  foot-board  applied  for  oontiiuious  extension. 
Fio.  Ijl. 


Encasement  in  immovable  gypsum 


,  <>.  Lure  of  leg.     (Stimson.") 


afler  the  first  dressing.     Bad  fractures  should  be  visited  within  a  few 
hours  after  the  original  dressing,  lest  unusual  swelling  may  have  occurred 


REPAIE    OF    FRACTURES.  343 

and  rendered  the  dressings  too  tight.  If,  after  the  second  dressing,  no 
undesirable  symptom  has  occurred  and  the  limb  feels  comfortable,  re- 
moval of  the  apparatus  is  not  called  for  oftener  than  two  or  three  times  a 
week.  Daily  inspection  of  the  patient  should,  however,  be  enforced  for 
ten  days  or  so,  even  if  no  change  is  made  in  the  dressing.  When  the  sur- 
geon takes  off  the  splints  the  limb  should  be  held  by  an  assistant,  who 
should  firmly  grasp  it  above  and  below  the  fracture  and  allow  no  motion 
or  displacement.  After  the  skin  has  been  washed  with  soap  and  water, 
or  with  alcohol,  the  limb  should  be  dried  and  carefully  examined  for 
abrasions  or  bedsores,  due  to  pressure,  and  for  any  renewal  of  deformity. 
It  should  ever  be  recollected  that  absence  of  discomfort  is  not  a  token  of 
absence  of  deformity.  Dressings  which  allow  the  seat  of  fracture  to  be 
always  under  observation  are  therefore  desirable,  though  it  is  not  always 
convenient  to  adopt  them. 

If  no  untoward  symptom  occurs  within  two  weeks,  change  of  dressing 
once  a  week  is  sufficiently  often ;  but  the  possibility  of  angular  displace- 
ment, even  so  late  as  four  or  five  weeks,  must  be  remembered.  Loosening 
of  bandages  or  sinking  in  the  be.d  may  cause  lateral  or  rotary  movement 
at  the  seat  of  fracture. 

Retention  apparatus  may,  as  a  rule,  be  discarded  in  uncomplicated 
fractures  of  the  upper  extremitj^  at  the  end  of  from  four  to  six  weeks,  and 
of  the  lower  extremity  at  from  six  to  eight  weeks.  The  bones  should  be 
subjected  to  no  muscular  strain  for  two  or  three  weeks  subsequently. 
During  this  time,  and  often  longer,  slings  or  crutches  are  needed.  The 
union  becomes  firm  in  children  sooner  than  in  adults. 

Persistent  pressure  of  the  splint  or  bed  upon  any  bony  protuberance  is 
liable  to  cause  a  localized  chronic  sloughing  of  the  skin  and  subcutaneous 
cellular  tissue,  technically  called  a  bedsore.  This  result  must  be  avoided 
by  careful  padding,  frequent  change  of  the  points  of  pressui-e,  and  bathing 
the  cutaneous  surface  with  water  or  alcohol.  A  patient  can  often  change 
his  posture  in  bed  without  detriment  if  a  rope,  attached  to  the  ceiling  over 
his  head,  is  allowed  to  hang  within  reach.  Bedsores  often  occur  without 
any  sensation  of  pain  or  burning.  The  surgeon  must  look  for  them,  and 
not  be  satisfied  with  a  reply  that  there  is  no  pain.  If  a  dark  spot  is  seen 
on  the  heel,  elbow,  sacrum,  or  other  prominence,  a  bedsore  already  exists. 
The  slough  must  be  detached  before  the  sore  will  get  well.  Hence,  moist 
antiseptic  dressings  should  be  applied  for  a  time.  The  ulcer  remaining 
after  the  detachment  of  the  slough  is  to  be  treated  by  antiseptic  dressings 
to  prevent  suppuration,  and  possibly  by  applications,  such  as  chloral  in 
solution  or  ointment  (gr.  x  to  9j),  nitrate  of  silver  and  iodoform. 

The  inflammatory  symptoms  at  the  seat  of  injury  in  closed  fractures 
usually  need  no  treatment.  Correct  apposition  and  prevention  of  motion 
are  the  essential  features.  The  blebs  that  sometimes  form  on  the  surface 
may  be  let  alone,  unless  they  are  large  ;  then  they  may  be  punctured  with 
a  needle  to  allow  the  bloody  or  straw-colored  serum  to  escape.  Wrapping 
the  limb  in  cloths  saturated  with  lead-water  and  laudanum,  before  apply- 
ing the  splints,  is  improper.  Such  measures  do  no  good,  and  the  dressings, 
acting  as  poultices,  may  cause  blebs  to  arise  which  otherwise  would  not 
have  appeared.  Muscular  spasm  about  fractures  is  best  combated  by 
morphia  given  by  the  mouth  or  hypodermically.  Retention  of  urine  re- 
quiring catheterization  is  not  infrequent  after  fracture  of  the  thigh. 
Abscesses,  traumatic  fever,  delirium,  tetanus,  erysipelas,  and  other  com- 
plications, must  be  treated  on  general  principles.  Gangrene  due  to 
arterial  rupture  or  thrombosis  simultaneous  with  the  fracture  occurs  at 


344 


DISEASES    AND    INJURIES    OF    BONES. 


times;  it  may  also  follow  constrictive  pressure  from  excessive  inflamma- 
tory swelling  beneath  the  skin  and  fascia.  When  the  last  condition  is 
feared,  free  cutaneou:^  and  fascial  incisions,  as  previously  descril)ed,  will 
relieve  the  tension  by  allowing  gaping,  and  thus  often  avert  the  calamity. 
Injudicious  bandaging  has  often  caused  gangrene.  In  gangrene  from  any 
of  these  causes  it  is  usually  well  to  wait  for  the  line  of  demarcation  before 
amputating.  If,  however,  the  destructive  process  is  rapidly  spreading, 
immediate  amputation  at  a  high  point  may  be  judicious. 

Fig.  1.V2. 


Suspended  and  fenestrated  gypsum  eneasement  for  fracture  of  leg. 


Immovable  or  fixed  dressings,  which,  however,  allow  no  inspection 
of  the  fractures,  are  oflen  used  when  the  fracture  has  been  reduced  and 
there  is  no  fear  of  swelling.  They  should  not  be  employed  in  the  early 
days  of  a  fracture.  It  is  much  safer  to  wait  until  all  inflammatory 
action  has  subsided  and  there  is  some  solidity  given  to  the  broken  bone 
bv  the  beginnings  of  repair.  The  end  of  the  second  or  third  week  is 
early  enough  for  their  employment.  Enca.sements  are  nuide  from 
bandages  or  cloths  saturated  with  gypsum,  silicate  of  sodium,  or  glue, 
as  has  been  mentioned  above  in  describing  moulded  .splints.  Before  the 
immovable  apparatus  is  applied  the  limb  should  be  smoothly  enveloped 
in  soft  flannel  or  a  layer  of  cotton  wadding.  Then  the  roller  bandage 
soaked  in  gypsum  should  be  applied  circularly  to  the  limb,  without  being 
drawn  at  all  tightly.  Silicate  of  sodium  solution  may  be  used  instead 
of  gypsum.  It  dries  more  slowly  than  gypsum,  but  makes  a  more 
elastic  encasement,  which,  when  split,  can  rather  more  readily  be  pulled 
apart,  so  that  the  limb  may  be  lifted  out  and  examined.  Such  a  split 
encasement  then  becomes  a  movable  splint.  I  usually  so  employ  the 
so-called  fixed  dressings.  As  the  limb  shrinks  because  of  absorption 
of  inflammatory  deposits,  the  splint  will  become  too  loose  and  allow 
displacement  of  the  fracture.  It  .should  then  be  removed  and  replaced 
by  a  new  one,  unless  it  is  elastic  enough  to  be  opened,  padded,  and 
reapplied.  Eyelets  and  laces  may  be  inserted  for  the  purpose  of  regu- 
lating the  degree  of  constriction.  The  seat  of  fracture  or  wound  may  be 
left  open  to  inspection  by  an  opening  in  the  encasement.  Powerful  shears 
are  the  best  instruments  for  dividing  fixed  dressings  which  are  to  be 
removed,  but  a  saw  or  knife  may  answer.  Gypsum  encasements  may  be 
softened  before  using  the  knife  by  applying  muriatic  acid  along  the  line 
of  proposed  division. 

Fractures  running  into  joints  are  apt  to  be  followed  by  ankylosis  be- 


TREATMENT  OF  OPEN  FRACTURES. 


345 


cause  of  the  arthritis  that  arises  secondarily  to  the  bone  injury.  The 
joints  adjacent  to  a  fracture  are  usually  kept  immovable  by  the  splints  in 
order  to  prevent  motion  at  the  point  of  fracture.  Hence,  when  the 
apparatus  is  finally  removed  these  joints  often  show  considerable  stiffness, 
due  to  disuse  for  several  weeks  and  to  the  inflammatory  exudate  among 
the  muscles  and  fascias.  Passive  motion  of  these  joints  by  the  surgeon  at 
the  time  of  rearranging  splints  during  the  treatment  of  the  broken  bone 
is  often  insisted  upon.  Such  motion,  unless  very  slight,  may  displace  the 
fragments.  Hence,  it  has  long  been  a  mooted  question  whether  the 
surgeon  should  commence  these  manipulations  early  or  late.  In  any  case 
where  there  is  probability  of  passive  motion  displacing  the  fragments  it 
should  not  be  commenced  until  firm  union  has  taken  place.  Four  weeks 
is  early  enough  in  all  these  doubtful  cases.  If  arthritis  has  occurred  as  a 
complication,  absolute  rest  is  indicated  and  passive  motion  will  do  harm. 
If  no  arthritis  has  occurred,  the  stiffness  due  to  disuse  can  readily  be 
overcome  by  passive  motion  at  a  later  date  when  there  is  no  risk  of  inter- 
fering with  bony  union.  Then  the  patient  can  supplement  the  passive 
motion  employed  by  the  surgeon  by  rubbing  and  moving  the  limb  with 
his  own  hands  or  pulling  against  a  resisting  force.  Passive  motion  which 
is  followed  by  pain  and  tenderness  of  the  joint  is  usually  deleterious,  for 
it  means  that  arthritis  exists. 

Fig.  153. 


Shears  for  cutting  through  gypsum  dressing. 

When  a  fracture  is  complicated  by  dislocation  of  a  neighboring  joint, 
the  surgeon  should  endeavor  to  reduce  the  dislocation  at  once.  The 
necessary  leverage  may  often  be  obtained  by  applying  such  temporary 
splints  as  will  steady  the  broken  bone.  Afterward  the  same  or  other 
fracture  dressings  mav  be  utilized  for  the  treatment  of  the  fracture. 


Treatment  of  Open  Fractures. 

The  treatment  of  open  fractures — ^that  is,  of  fractures  complicated  by 
a  wound  leading  to  the  seat  of  fracture  which  communicates  with  the 
air — varies  with  the  character  of  the  injury.  The  indications  are  to 
replace  and  retain  the  fragments  in  apposition  and  obtain  rapid  healing 
of  the  wound.  The  last  indication  is  usually,  though  not  always, 
possible  of  fulfilment  if  the  wound  is  promptly  made  aseptic  and  kept 
so.  Hence,  the  surgeon,  after  reduction  of  the  fracture,  should  cleanse 
the  wound  with  antiseptic  washes,  such  as  corrosive  sublimate  solu- 
tion (1  :  500  or  1000),  and  treat  it  so  as  to  avoid  virulent  consecutive 
inflammation  due  to  infection.  When  a  portion  of  the  bone  protrudes 
through  the  skin,  manipulation,  relaxation  of  muscles,  enlargement  of 
the  wound,  tenotomy,  and  resection  of  the  ends  of  the  fragments  should 
be  practised  to  accomplish  replacement.      When  the  bones  constantly 


346  DISEASES    AND    INJURIES    OF    BONES. 

slip  out  of  apposition  resort  should  be  had  to  wiriiiL'  them  together 
by  means  of"  holes  drilled  obliquely  through  the  extremities,  or  by 
drivMug  sterilized  bone  pins  or  steel  nails  into  the  osseous  tissue  and 
twisting  the  wire  around  them.  Loose  splinters  and  all  foreign  bodies 
should  be  jiiekod  out  of  the  wound.  Portions  of  bone  still  maintaining 
periosteal  attachments  should  be  permitted  to  remain.  Fractures  com- 
plicated with  wounds  are  almost  certain  to  suppurate  unless  they  are 
managed  with  rigid  antisepsis,  because  they  have  been  infected  before 
they  are  seen  by  the  sui'geou.  They  should  be  thoroughly  washed  out  by 
antiseptic  lotions  after  the  surrounding  parts  have  been  scrubbed  with 
soap  and  water  under  anaesthesia,  and  only  closed  after  provision  for  free 
drainage  has  been  made  by  means  of  counter-incisions  and  drainage-tubes. 
All  dirt  and  foreign  material  must  be  removed.  The  method  of  render- 
ing such  injuries  aseptic  has  been  described  under  the  Treatment  of 
Wounds ;  for  an  open  fracture  is  a  lacerated  wound  of  soft  parts  and 
bone.  When  washing  out  an  open  or  compound  fracture  with  tlie  anti- 
septic solution,  provision  should  be  made  for  the  outflow  of  the  blood- 
stained fluid,  so  as  not  to  leave  poisonous  fluid  in  the  cavity  on  the  one 
hand  or  to  fail  to  get  rid  of  sej)tic  bacteria  on  the  other.  Counter-open- 
ings or  enlargement  of  the  original  wound  may  be  demanded  for  this 
object.  Intramuscular  or  subcutaneous  lacerations  often  extend  up  and 
down  the  limli  a  long  distance  from  the  seat  of  fracture.  These  may  re- 
quire long  incisions  in  order  that  efficient  disinfection  may  be  accom- 
jtlished.  After  thorough  irrigation,  the  wound  is  to  be  dressed  on  general 
principles  with  a  voluminous  antiseptic  gauze  dressing.  If  the  attempt 
to  get  primary  union  has  failed,  the  first  indication  of  suppuration  is  to 
be  followed  by  immediate  opening,  sterilization,  and  drainage  of  the 
wound.  The  surgeon's  nails,  hands,  and  instruments  must  be  sterilized 
before  undertaking  these  manipulations.  Failure  to  get  primary  union 
of  the  soft  parts  is  evidence  that  the  wound  was  not  made  sterile. 

Ordinary  fracture  apparatus,  to  maintain  proper  position  of  the  frag- 
ments, must  next  be  applied  outside  of  the  gauze  dressings. 

When  a  simple  fracture  shows  signs  of  becoming  open  because  of 
cutaneous  sloughing,  an  effort  should  be  made  to  prevent  as  long  as 
possible  the  separation  of  the  eschar  by  keeping  it  aseptic. 

Some  oi)en  fractures  demand  immediate  amputation,  l)ecause  the  injury 
is  so  severe  that  the  sloughing  sure  to  follow  will  probably  prove  fatal. 
If,  after  an  attempt  to  save  the  limb,  unexpectedly  severe  symptoms 
occurred,  it  was  formerly  considered  to  be  usually  better  to  delay  ampu- 
tation until  sui)puration  and  sloughing  had  been  fully  established.  In 
other  words,  intermediary  amputations  in  such  injuries  were  apt  to  be 
disastrous.  Immediate  amputations — that  is,  those  done  as  soon  as  reaction 
from  shock  had  occurred,  and  those  done  after  the  lapse  of  about  ten  days, 
when  suppuration  was  fully  established — were  thought  more  likely  to  be 
followed  by  recovery.  This  is  no  longer  a  rule,  as  antiseptic  methods 
have  altered  the  clinical  history  of  all  wounds,  and  will  reduce  the  amount 
of  suppuration  and  the  degree  of  septic  poisoning  in  those  cases  where 
the  impossibility  of  obtaining  a  sterile  wound  has  prevented  primary 
union. 

Antiseptic  methods  have  enabled  surgeons  to  save  many  limbs  sub- 
jected to  open  fractures,  that  under  previous  methods  of  treatment  would 
have  required  immediate  amputation  to  save  life.  Almost  any  open  frac- 
ture in  which  the  tissues  are  not  absolutely  devitalized  can  be  successfully 
treated  if  made  perfectly  sterile  and  kept  so.     I  have  been  astonished  at 


UNUNITED    FRACTURE    OR    P  SE  U  D  A  RTHROSIS.  347 

my  success  in  these  cases.  Amputation  is  usually  required  in  railway  and 
other  injuries  which  cause  crushing  of  the  bones  and  pulpefaction  of  the 
soft  parts.  Similar  treatment  is  often  demanded  w^hen  the  main  artery 
has  been  opened  by  the  injur3^  In  the  upper  extremity  conservative  sur- 
gery is  attended  with  less  risk  to  life  than  in  the  lower  limb.  Moreover, 
the  fact  that  artificial  legs  are  very  serviceable,  while  artificial  hands  and 
arms  are  j^ractically  useless,  argues  something  in  favor  of  not  taking  too 
much  risk  by  trying  to  preserve  a  doubtful  leg.  It  must  be  remembered, 
however,  that  amputations  high  up  in  the  thigh  for  any  cause  have  a 
somewhat  high  death-rate.  Open  fractures  involving  large  joints  may 
often  be  treated  by  primary  or  secondary  excision  of  the  joint  instead  of 
amputation.  Gunshot  fractures  involving  joints  are  an  exceedingly  serious 
form  of  open  fractures.  If  in  open  fractures  running  into  joints  the 
limb  is  to  be  saved,  antiseptic  cleansing,  free  drainage,  perhaps  by  many 
counter-openings,  antiseptic  irrigation,  and  in  extensive  fracturing,  ex- 
cision must  be  the  resorts  of  the  surgeon.  Excision  may  sometimes  be 
delayed  and  performed  as  a  secondary  operation  when  it  can  be  better 
determined  how  much  bone  must  be  sacrificed.  Rigid  and  thorough  pro- 
vision for  escape  of  all  wound  fluids  must  be  insisted  upon  in  all  these 
injuries.     Drainage  is  an  essential  factor  in  open  fractures. 

Ununited  Fracture  or  Pseudarthrosis. 

Pathology. — It  is  occasionally  found  that  some  degree  of  mobility 
and  pain  on  motion  persists  after  the  lapse  of  what  ordinarily  would  be 
sufficient  time  to  cause  consolidation  of  a  given  fracture.  Such  instances 
are  denominated  cases  of  delayed  union.  If  successive  weeks  or  months 
pass  without  union  occurring  at  the  seat  of  fracture,  the  condition  is  un- 
united fracture,  false  joint,  or  pseudarthrosis.  Delayed  union  is  usually 
the  result  of  deteriorated  general  health,  while  false  joint  in  almost  all 
instances  depends  upon  some  local  condition  pertaining  to  the  fragments 
themselves.  Many  cases  of  delayed  union  finally  terminate  in  complete 
consolidation  without  any  special  treatment  beyond  building  up  the  pa- 
tient's health.  False  joints,  however,  whether  sequences  of  delayed  union 
or  cases  showing  from  the  beginning  no  tendency  to  union,  persist,  and 
require  either  the  adaptation  of  apparatus  to  supply  the  normal  rigidity 
of  the  limb  or  active  and  judicious  surgical  treatment.  Efficient  appara- 
tus is  more  easily  obtained  for  non-union  in  the  upper  than  in  the  lower 
limb,  because  of  the  weight-sustaining  function  of  the  latter. 

It  is  not  customary  to  apply  the  term  ununited  fracture  to  the  fibrous 
union  that  frequently  occurs  when  short,  spongy  bones  and  the  spongy 
ends  of  long  bones  are  broken,  or  when  prominences  for  muscular  attach- 
ment are  torn  loose.  These  fractures  would  probably  unite  by  ossific 
deposition,  as  other  fractures  do,  if  correct  apposition  was  obtained  and 
maintained.  They  actually,  therefore,  are  cases  of  unuited  fracture, 
though  not  called  so.  The  bond  of  union  holding  the  fragments  together 
after  healed  fracture  occasionally  undergoes  softening  and  absorption 
during  the  progress  of  phlegmonous  inflammation  of  the  limb,  scurvy,  or 
other  grave  disorder.  It  is  manifestly  improper  to  apply  the  term  un- 
united fracture  to  this  condition  when  it  occurs  subsequent  to  complete 
union  of  the  osseous  lesion.  Atrophy  of  the  bone  itself  sometimes  occurs 
after  fracture. 

Ununited  fracture  is  a  comparatively  rare  condition.     The  cases  may 


348  DISEASES    AND    IXJL'RIES    OF    BOXES. 

be  divided  into  three  classes  :  1,  those  in  which  there  is  no  bond  whatever; 
2,  those  in  which  there  is  more  or  less  successful  attempt  at  union  by  means 
of  bands  of  fibrous  tissue  and  nodules  of  bone ;  3,  those  in  which  a  crude 
joint  is  formed  as  exhibited  by  cartilaginous  material  on  the  apposing 
surfaces  of  bone,  synovial  fluid,  and  a  capsule.  The  first  and  third  varie- 
ties are  very  unusual.  The  second  form  is  that  usually  found  when  un- 
united fractui'es  are  dissected.  The  length  and  disposition  of  the  fibrous 
bands  vary  in  accordance  with  the  relation  of  the  fragments.  There 
may  be  a  mass  of  callus  partially  ossified  and  little  fibrous  tissue ;  or  little 
callus  with  bands  of  fibrous  tissue  uniting  the  fragments  somewhat  like 
interosseous  ligaments.  This  kind  of  non-union  gives  a  flail-like  limb  if 
the  bands  of  fibrous  tissue  are  long.  It  is  more  movable  than  the  form 
described  as  having  a  joint-like  structure. 

Causes. — Syphilis,  pregnancy,  advanced  age,  acute  diseases,  and  other 
sources  of  physical  deterioration  and  malnutrition  have  been  described  as 
causes  of  ununited  fracture.  They  apparently,  however,  have  little  influ- 
ence in  giving  rise  to  non-union,  though  delayed  union  may  perhaps  be 
due  to  them.  Xon-union  is  nearly  always  the  result  of  a  local  cause,  and 
this  local  cause  is  usually  mechanical.  The  most  fre((uent  agencies  are : 
(1)  unfavorable  relation  of  parts,  such  as  great  separation  of  the  frac- 
tured surfaces  by  reason  of  displacement,  actual  loss  of  substance,  or 
necrosis  ;  (2)  defective  treatment,  by  which  immobility  of  the  fragments  is 
not  secured  ;  (3)  portions  of  fascia  or  muscle,  and  bullets  or  other  foreign 
bodies  lying  between  the  fragments ;  malignant  and  other  growths  in  the 
same  location.  Destruction  of  the  nerves  coming  from  the  trophic  centres 
in  the  lower  part  of  the  spinal  cord,  or  of  the  centres  themselves,  has  been 
with  apparent  reason  assigned  as  a  cause  of  ununited  fracture  or  pseudar- 
throsis.  It  is  also  stated  that  softening  or  absorption  of  callus  may  follow 
the  too  early  use  of  a  broken  limb.  This  occurrence  is  doubtless  the 
result  of  motion  at  the  seat  of  a  partially  ossified  callus  union  and  comes 
under  the  head  of  defective  treatment  mentioned  above. 

DiA(iN'0.srs. — The  diagnosis  of  ununited  fracture  is  made  by  preter- 
natural, and,  in  most  cases,  painless  mobility  existing  long  after  the  time 
for  consolidation  has  passed.  Near  a  joint  such  mobility  may  simulate 
the  normal  articular  movement ;  or,  a  joint  with  relaxed  ligaments 
may  simulate  ununited  fracture.  The  character  of  the  defective  union 
is  often  obscure.  If  it  is  simply  delayed,  an  elastic  mass  of  callus, 
which  is  the  seat  of  pain  on  strong  passive  motion,  will  probably  be 
discerned  by  i)alpation.  If  a  crude  joint  has  been  developed,  no  callus 
and  no  pain  will  be  found  ;  nor  will  the  flail-like  mobility  of  long  fibrous 
attachment  exist.  Careful  palpation  and  puncture  with  long  needles  will 
at  times  determine  the  position  and  shape  of  the  fragments. 

Treatment. — The  treatment  of  delayed  union  consists  in  friction  of 
the  limb,  change  of  air,  nourishing  diet,  and  the  administration  of  alka- 
line phosphates  and  carbonates,  and  of  tonics.  A  few  additional  weeks 
under  good  hygienic  circumstances  is  all  that  is  usually  demanded. 

Ununited  fractures,  whether  fibrous  or  articular,  demand  much  more 
active  measures,  of  which  the  milder  forms,  however,  should  first  be 
employed.  Rectification  of  any  displacement  that  seems  to  interfere 
with  union  should  be  accomplished,  after  which  the  immovable  gypsum 
dressing  should  be  applied  and  worn  for  a  month.  If  any  increase  of 
consolidation  is  observed  this  dressing  should  be  continued  for  several 
months,  during  which  time  the  patient  may  go  about  on  crutches  if  it  is 
the  lower  limb  which  is  the  seat  of  injury.     If  the  part  becomes  painful 


UNUNITED    FRACTURE    OR    P  SEU  D  A  RTH  RO  SI  S.  349 

from  excoriation,  the  encasement  may  be  split  and  laced  or  removed,  and 
a  new  one  applied.  The  latter  method  is  probably  the  better.  During 
this  period  the  hygienic  measures  noted  above  for  delayed  union  should 
be  adopted.  The  application  of  the  descending  constant  current  has  been 
recommended,  but  is  probably  valueless. 

Failure  to  accomplish  anything  by  these  plans  necessitates  the  adoption 
of  operative  measures,  unless  more  support  by  apparatus  to  give  rigidity 
is  acceptable  to  the  patient  and  surgeon. 

The  operative  plans  aim  either  at  setting  up  inflammatory  action  at  the 
seat  of  non-union,  and  thus  stimulating  functional  activity;  or,  at  con- 
verting the  old  ununited  fracture  into  a  recent  one  with  freshly-sawed  sur- 
faces in  apposition.  Violent  bending  and  rotation,  such  as  will  tear  apart 
the  fibrous  connections  and  cause  the  ends  of  the  fragments  to  be  rubbed 
upon  each  other,  will  often  be  followed  by  consolidation.  These  manipu- 
lations may  be  repeated  daily  until  tenderness  and  swelling  follow.  Upon 
the  appearance  of  these  symptoms  the  limb  should  be  immobilized  in 
splints  and  treated  as  a  recent  fracture.  As  a  rule,  the  fibrous  union  can 
at  one  sitting  be  torn  up  and  the  ends  rubbed  with  sufficient  degree  of 
force  to  cause  the  advent  of  tenderness  on  the  following  day.  The  bones 
may  be  bent  at  right  angles  and  extensively  rotated  and  extended 
without  endangering  the  safety  of  vessels  or  other  tissues.  To  be  oi 
service  the  manipulation  must  be  thoroughly  done ;  usually  under  influ- 
ence of  an  aneesthetic.  When  the  operation  does  not  succeed  in  causing 
deposition  of  callus  and  consequent  union,  subcutaneous  drilling  of 
the  fragments  may  be  tried.  A  bone  drill  is  introduced  through  a 
small  puncture  in  the  skin  and  the  ends  of  the  fragments  perforated  in 
various  directions.  Afterward  retention  apparatus  is  applied.  Ostitis 
is  the  result  of  this  treatment,  and  may  be  followed  by  union.  A  similar 
ostitis  has  been  induced  by  driving  an  ivory  peg  through  or  into  each  frag- 
ment, in  which  a  hole  has  been  previously  made  by  means  of  a  drill.  The 
fibrous  bands  should  previously  be  ruptured  by  passive  motion.  The  pegs, 
which  do  not  piu  the  bones  together,  are  withdrawn  in  a  few  days  when 
pain  is  felt  in  the  osseous  tissue.  A  better  plan,  when  practicable,  is  to 
bore  holes  into  the  fragments  and  pin  them  together  by  means  of  metal 
screws  or  pegs  of  ivory  or  bone.  These  may  be  cut  or  broken  off  close  to 
the  surface  of  the  bone,  and  the  tissues  allowed  to  heal  over  them.  Thus 
the  fragments  are  held  in  position  while  productive  ostitis  furnishes  callus 
to  join  them  firmly  and  permanently.  The  ivory  and  bone  pegs  will  be- 
come absorbed,  the  steel  screws  encysted.  If  the  surgeon  prefers,  the 
screws  or  pegs  may  be  allowed  to  project  from  the  wounds  of  entrance 
and  be  withdrawn  in  two  or  three  weeks,  when  consolidation  is  partly 
accomplished.  This  method  is  more  apt  to  permit  purulent  infection  and 
cause  suppuration  than  the  former,  but  may  in  some  instances  be  prefer- 
able.    The  bone  pegs  are  readily  made  from  bone  knitting  needles. 

The  most  radical  operation  for  ununited  fracture  is  resection  of  the 
w^ounded  ends  of  bone.  It  makes  an  open  fracture,  but  it  is  often  the 
only  method  that  will  lead  to  a  cure.  This  is  especially  so  in  cases  where 
the  non-union  has  caused  the  formation  of  a  joint-like  structure,  and 
where  the  failure  of  union  is  due  to  dead  bone  or  portions  of  muscle  be- 
tween the  ends  of  the  fragments.  The  danger  formerly  belonging  to  this 
procedure  is  obviated  by  the  methods  of  antiseptic  surgery.  Suppuration 
will  seldom  occur.  A  longitudinal  incision  is  made,  the  ends  of  bone 
turned  out  and  sawed  oflT  after  saving  as  much  as  possible  of  the  perios- 
teum, the  limb  put  up  in  splints,  and  the  wound  treated  antiseptically,  as 


3oO  DISEASES    AND    INJURIES    OF    BONES. 

in  open  fractures.  The  chisel,  bone  cutters,  or  saw  may  be  used  to  remove 
the  pieces  of  bone.  Sometimes  the  ends  mav  with  advantage  be  fastened 
together  by  wire,  sterilized  bone  pegs  or  screws,  as  in  accidental  open 
fracture.  These  substance.^  may  be  cut  oti  short  and  left  in  the  wound, 
or  be  taken  out  in  about  three  weeks.  As  little  as  po^^sible  of  the  bone 
should  be  sacrificed,  only  enough  to  give  a  broad,  fresh  surface  of  contact. 
Sometimes  shoulders  are  cut  so  that  the  fragments  may  bo  interlocked 
or  mortised  together.  Transplantation  into  the  gap  of  small  portions 
of  bone  from  the  hunuin  subject  or  from  lower  animals  has  been  prac- 
tised with  apparent  success.  It  may  hai)pen  that  the  excision  of  the  ends 
of  the  fragments  with  pegging  or  wiring  them  together  will,  if  done  anti- 
septically,  produce  so  little  irritation  that  there  is  not  enough  productive 
inflammation  to  cause  union.  AVhen  this  is  feared,  it  is  best  to  leave  the 
wound  in  the  soft  parts  open  and  plug  it  with  antiseptic  gauze,  so  that 
more  irritation  will  be  induced  and  union  occur  only  by  second  intention. 
The  outside  dressing  must  be  carefully  applied,  so  as  to  prevent  putrefac- 
tive or  purulent  infection.  Death  frecjueiitly  occurred  formerly  after 
operations  for  ununited  fracture  from  suppuration  and  sepsis. 

Amputation  is  not  to  be  considered  in  cases  of  ununited  fracture,  except 
under  exceptional  circumstances,  and  when  resection  or  one  of  the  other 
operations  has  been  followed  by  gangrene  or  diffuse  sup|)uration. 

Deformed  or   Vicious   Union  of  Fractures. 

Pathology. — Absence  of  jiroper  treatment  in  cases  of  fracture  often 
gives  rise  to  deformed  union,  because  callus  will  be  furnished  and  consoli- 
dation of  the  bony  structures  usually  occurs,  even  when  the  fragments 
have  not  been  placed  in  correct  apposition.  Great  disability  may  thus 
result,  especially  in  the  lower  limb.  Angular  deformity  or  overlapping 
will  cause  shortening  ;  the  presence  of  an  abnormal  projection  near  a  joint 
may  interfere  with  flexion  and  other  articular  movements.  Change  in 
the  long  axis  of  the  fragments  and  rotation  may  cause  the  weight  of  the 
body  to  throw  unusual  strain  on  the  lateral  ligaments  of  the  knee  and 
ankle,  and  produce  secondary  deformity  in  these  situations.  Vicious 
union  may  also  give  trouble  by  causing  ])ainful  pressure  upon  nerves,  or 
by  inducing  ulceration  of  the  skin  over  projecting  portions  of  bone.  In 
the  forearm  pronation  and  supination  may  be  obstructed  by  bridges  or 
masses  of  callus  attached  to  the  radius  and  ulna.  Deformed  union  some- 
times allows  muscles  and  tendons  to  become  entangled  in  the  callus,  and 
thus,  if  not  remedied  at  an  early  day,  gives  rise  to  permanent  impairment 
of  muscular  action. 

There  are  two  methods  of  treatment:  subcutaneous  refracture,  and  divi- 
sion of  the  deformed  union.  The  former  is  less  dangerous  than  the  latter, 
and,  in  fact,  is  practically  devoid  of  danger,  because  it  merely  creates  a 
closed  fracture  which  unites  promptly,  and  there  is  naturally  much  less  dis- 
turbance of  the  soft  parts  than  in  similar  fractures  of  accidental  origin. 
Hence  little  reaction  follows.  Experience  shows  that  refracture  or  rup- 
ture can  be  done  as  late  as  six  and  twelve  months  after  cousolidation  has 
occurred,  and  that  with  proper  precautions  the  bone  need  never  be  broken 
at  other  than  the  seat  of  original  injury.  Gradual  bending  and  attempts 
to  soften  the  callus  by  applications  or  medication  are  a  useless  waste  of 
time. 

Angular  deformity  is  the  variety  that  most  frequently  demands  cor- 


DEFOKMED    OK    VICIOUS    UNION    OF    FRACTURES.      351 

rection.  Fortunately  it  is  also  the  most  amenable  to  improvement. 
Refracture  of  malunion  a  few  weeks  old  can  usually  be  accomplished  by 
seizing  the  limb  firmly  with  the  hands  and  forcibly  bending  the  bone  at 
the  seat  of  the  old  fracture.  The  bending  is  generally  made  in  such  a 
way  as  to  attempt  at  once  straightening  the  bone.  Sometimes  it  is  better 
to  bend  first  in  the  direction  of  the  flexion,  as  is  done  in  breaking  up  an 
ankylosed  knee.  It  may  be  necessary  to  place  a  fulcrum,  such  as  the 
operator's  knee  or  a  block  of  wood,  against  the  convex  surface  of  the 
angular  deformity.  Another  method  is  to  have  the  limb  projecting  over 
the  edge  of  a  table  and  steadied  upon  the  table  by  an  assistant,  while  the 
operator  takes  the  distal  end  and  suddenly  throws  his  weight  upon  it.  A 
sudden  force  is  much  more  effectual  than  gradual  bending,  which  will  be 
found  unavailable  in  all  but  recent  cases.  It  is  often  well  to  bind  a 
straight  splint  to  the  limb  beloAv  the  seat  of  proposed  refracture  and 
another  above  it,  but  neither  of  them  should  overlap  the  mass  of  callus. 
These  splints  prevent  motion  and  strain  of  the  joints,  give  the  operator 
more  leverage,  and  avoid  the  remote  possibility  of  fracturing  at  any  other 
than  the  desired  point.  Strong  extension  and  counter-extension  by  means 
of  pulleys  may  be  applied  at  the' time  the  cross-breaking  strain  is  exerted. 
The  attachment  of  the  pulley-rope  can  be  satisfactorily  made  by  the 
notched  extension  plate  of  Dr.  R.  J.  Levis.  When  shortening  is  great 
it  may  be  well  to  continue  anaesthesia  and  excessive  extension  for  an  hour 
or  so  after  refracture,  to  gain  as  much  length  as  possible  before  dressing. 
Some  form  of  osteoclast,  such  as  Taylor's  or  Rizzioli's,  may  be  employed 
in  very  firm  consolidation.^ 

Fig.  154. 


Levis's  notched  extension  plate. 


When  the  deformity  depends  upon  lateral  application  of  the  two  bony 
cylinders  rupture  must  be  attempted  by  flexion  across  the  bond  of  union, 
combined  with  rotation  in  the  axis  of  the  limb,  and  strong  extension  and 
counter- extension.  These  cases  are  not  as  amenable  to  treatment  as 
angular  malunion. 

Division  of  the  deformed  union  should  only  be  employed  when  correc- 
tion by  refracture  is  impossible,  because  it  creates  an  open  fracture,  and 
may  lead  to  suppurative  dangers  from  neglect  of  antiseptic  precautions. 
An  incision  in  the  soft  parts  is  made,  and  through  this  a  small  chisel  or 
saw  is  introduced.  The  callus  is  then  divided,  the  deformity  corrected, 
and  dressings  applied  as  in  open  fractures.  If  simple  division  of  the  bony 
tissue  will  not  permit  adjustment,  or  if  the  tissues  of  the  concavity  are  very 
tense,  a  wedge-shaped  piece  with  its  base  at  the  couA-ex  surface  may  be 
excised. 

^  See  Edinburgh  Medical  Journal,  July  and  August,  1878. 


352 


DISEASES    AND    INJURIES    OF    BONES. 


Projecting  spurs  of  bone,  acting  deleteriously  because  of  pressure  or 
their  position  near  joints,  may  be  removed  with  the  saw  or  cutting  forceps, 
very  much  as  an  exostosis,  and  usually  with  as  little  risk.     The  operative 


Fig.  155. 


Taylor's  osteoclast. 


treatment  of  mahinion  in  the  foi-earm  interfering  with  pronation  and 
supination  is  surrounded  with  a  good  deal  of  difficulty.  In  some  cases 
division  or  excision  of  callu.s  is  justifiable. 

Special  Fractures. 
Fractures  of  the   Vertebi'ce. 

Fractures  of  the  vertebral  column  derive  their  chief  importance  from 
the  damage  to  spinal  cord  and  nerve  trunks,  which  so  often  accompanies 
them.  The  spine  requires  solidity  and  flexibility  in  order  to  give  support 
and  movement  to  the  head,  trunk,  and  limbs  ;  but  its  protective  function, 
as  regards  the  s]>inal  cord,  is  even  more  essential  to  life  and  health.  As 
in  cranial,  so  in  spinal  fractures,  the  surgeon  is  more  anxious  concerning 
the  integrity  of  the  contained  nerve  elements  than  he  is  about  the  osseous 
lesion. 

The  vertebral  column  quite  frequently  sustains  fracture  from  an  in- 
direct violence  which  tends  to  produce  over-extension  or  over-flexion  of 
its  normal  curvatures.  For  example,  a  man  falling  from  a  height  on  his 
head  or  buttocks,  or  being  crushed  under  a  weight  falling  from  above 
upon  his  head  or  shoulders  sustains  a  fracture  of  the  spine,  because  the 
limit  of  flexion  or  extension  has  been  exceeded  and  the  bony  segments  are 
crushed  or  lacerated  by  the  force.     The  fracture  in  such  instances  usually 


FRACTURES    OF    THE    VERTEBRA.  353 

occurs  where  a  cflovable  portion  of  the  column  joins  a  more  rigid  portion, 
because  here  the  sudden  check  to  movement  occurs.  Hence,  clinical  ex- 
perience shows  spinal  fractures  from  this  form  of  injury  to  be  more  frequent 
near  the  dorso-lumbar  junction  and  in  the  vicinity  of  the  fifth  and  sixth 
cervical  vertebrae. 

Pathology. — The  bodies  of  the  vertebrae  seem  to  suffer  from  fracturing 
forces  oftener  in  the  lower  than  the  upper  region  ;  while  the  arches 
are  more  frequently  broken  in  the  neck  than  elsewhere.  Fracture  of  the 
spinous  process  occurs  most  often  in  the  dorsal  region.  The  lines  of 
fracture  and  the  number  of  vertebrae  involved  depend  upon  the  direction 
and  degree  of  the  force.  Dislocation  often  accompanies  the  fracture. 
Indeed,  the  two  conditions  are  frequently  indistinguishable  except  by 
post-mortem  examination. 

Contusion,  compression,  and  laceration  of  tlie  spinal  cord  may  be 
caused  by  displacement  of  the  fragments.  It  requires  considerable  dis- 
placement to  pinch  the  cord,  for  the  canal  is  much  wider  than  the 
spinal  cord  and  its  membranes.  As  the  cord  ends  at  the  level  of  the  first 
or  second  lumbar  vertebra,  fracture  below  this  point  can  only  compress 
the  leash  of  nerve  roots  and  branches  called  the  Cauda  equina  or  horse- 
tail. Hemorrhage  from  the  venous  plexuses  between  the  bony  wall  and 
the  dura  mater  may  be  a  result  of  the  fracture.  Such  hemorrhage  and 
inflammatory  products  may  exert  pressure  on  the  nervous  structures. 
Extravasations  of  blood  into  the  cellular  tissue  in  front  of  and  around 
the  spinal  column  often  occur,  and  after  a  time  may  appear  upon  the 
surface  of  the  face,  chin,  neck,  and  other  regions. 

Symptoms. — There  is  often  in  vertebral  fractures  no  noticeable  de- 
formity, preternatural  mobility,  or  crepitation.  The  diagnosis  must  then 
depend  upon  the  rational  symptoms,  which  are,  for  the  most  part,  refer- 
able to  lesion,  either  primary  or  secondary,  of  the  spinal  marrow.  De- 
pression may  sometimes  be  discovered  over  a  fractured  spinous  process  or 
vertebral  arch,  or  an  angular  prominence  may  be  perceptible  posteriorly 
after  crushing  fractures  of  one  or  more  vertebral  bodies.  Unusual 
mobility  may  be  observed  at  times,  especially  in  fractures  of  the  cervical 
region,  and  occasionally  movable  regions  may  become  more  or  less  immobile, 
because  of  spasmodic  contraction  of  the  muscles  about  the  fracture,  or 
because  of  interlocking  of  the  fragments.  Crepitation  may  be  present, 
absent,  or  discernible  only  by  the  patient.  The  manner  in  which  the 
spinal  column  is  bound  together  with  ligaments  and  surrounded  with 
muscles  often  prevents  the  discovery  of  these  symptoms  of  fracture,  even 
when  extensive  fracturing  exists.  Localized  pain,  increased  by  manipu- 
lation or  motion,  is  usual  in  fracture  of  the  vertebrae,  but  is  not  diagnostic 
of  the  character  of  the  injury. 

In  spinal  fractures  intelligence  is  unimpaired,  except,  perhaps,  during 
the  stage  of  shock.  Paralysis  of  the  parts  supplied  by  the  nerve  branches, 
leaving  the  cord  at  or  below  the  seat  of  injury,  is  a  common  symptom.  In 
locating  a  fracture  by  this  symptom  it  must  be  recollected  that  the  nerve 
roots  and  branches  run  obliquely  downward  within  the  vertebral  canal, 
and  do  not  escape  at  the  inter-vertebral  openings  corresponding  to  their 
points  of  origin  from  the  medulla.  For  example,  paralysis  of  the  legs 
and  trunk,  extending  as  high  as  the  distribution  of  the  first  lumbar  nerve, 
would  suggest  that  the  fracture  was  located  about  the  eleventh  or  twelfth 
dorsal  vertebra.  The  paralysis  is  usually  both  motor  and  sensory,  and  is 
partial  or  complete,  according  to  the  character  of  lesion  in  the  cord. 
When  complete,  the  area  of  cutaneous  insensibility  is  sharply  defined. 

•2'6 


354  DISEASES    AND    INJURIES    OF    BONES. 

Pricking  the  surface  with  the  point  of  a  pin  is  an  easy  method  of  deter- 
mining the  paralyzed  area,  and  of  estimating  its  increase  as  the  cord 
becomes  involved  in  inrian)matory  processes  extending  ii})\vard.  The  lower 
limbs  alone  will  be  motionless,  if  the  fracture  is  below  the  origin  of  the 
hracbial  plexus.  Otherwise  the  arms  will  be  paralyzed  also.  There  is 
usually  no  reflex  contraction  upon  pricking  or  pinching  the  paralyzed 
limbs,  and  electrical  contractility  is  soon  lost.  If  the  paralysis  is  incom- 
plete, hot  and  cold  sensations  maybe  distinguished.  Sometimes  cutaneous 
hypersesthesia  exists.  Darting  pains  may  be  felt  in  the  limbs  when  the 
partially  paralyzed  extremities  are  moved,  though  spinal  j)re.ssure  elicits  no 
such  sympt(mi.  The  occurrence  of  such  pains  is  under  some  circumstances 
a  sign  of  returning  innervation,  and,  therefore,  a  symptom  of  beginning 
improvement.  Tonic  or  clonic  spasms  of  the  muscles  are  occasionally 
observed,  and  may  be  excited  by  manipulation,  drafts  of  cold  air,  and 
similar  irritants.  The  paralysis  may  not  be  present  immediately  after 
injury,  but  may  supervene  upon  movement  causing  displacement,  or  ari.se 
from  an  intraspinal  hemorrhage  or  the  development  of  inflammation  of 
the  cord  or  its  mend^ranes.  The  superficial  branches  of  nerves  coming 
from  the  medulla  above  the  lesion  may  supply  the  integument  for  a  con- 
siderable distance  below  the  injury,  and  thus  deceive  the  surgeon  as  to 
the  location  of  the  fracture. 

As  a  result  of  the  ])aralysis  retention  of  urine  occurs,  to  be  followed 
after  a  time  by  overflow  and  incontinence.  Alkaline  fermentation  of  the 
urine  within  the  bladder,  and  cystitis,  soon  supervene.  Constipation,  fol- 
lowed by  incontinence  of  feces,  is  another  paralytic  phenomenon.  Tym- 
panitic distention  of  the  abdomen  also  takes  place.  In  fracture  of  the 
upper  regions  the  respiratory  distress  due  to  paralysis  of  the  abdominal 
and  other  muscles  of  respiration  is  increased  by  this  tympanitic  distention, 
which  prevents  full  descent  of  the  diaphragm.  Bedsores  appear,  often 
within  two  or  three  days,  because  the  insensitive  and  motionless  limbs  do 
not  change  the  points  of  pressure.  The  probable  occui-rence  of  bedsores 
is  increased  by  the  difficulty  of  keeping  the  sheets  free  from  urine  and 
feces,  which  are  evacuated  unconsciously. 

Persistent  vomiting  and  marked  elevation  of  temperature  of  the  palsied 
region  have  l)een  observed  in  fractures  of  the  upper  part  of  the  spine. 

Priapism,  more  or  less  marked,  is  a  common  accompaniment  of  spinal 
fracture.  It  seems  to  diminish  in  frequency  as  the  injury  occurs  lower 
in  the  vertebral  column.  Seminal  emissions  sometimes  take  place.  In- 
troduction of  the  catheter  to  relieve  the  distended  bladder,  though  not 
felt  by  the  patient,  may  increase  the  erection  or  cause  a  partial  erection 
if  none  was  previously  present.  I  am  not  cognizant  of  erection  of  the 
clitoris  having  been  noted  in  females  suffering  from  fracture  of  the  spine. 
Analogy  suggests  its  probable  occurrence. 

A  careful  clinical  study  of  the  symptoms  of  spinal  injuries  will  lead  to 
a  more  correct  localization  of  the  seat  of  fracture  than  is  possible  by  a 
cursory  survey  of  the  case.  Spinal  localization,  as  cerebral  localization, 
needs  more  consideration  at  the  hands  of  surgeons.  This  matter  has 
been  referred  to  in  the  chapter  on  Intraspinal  Inflammation.  Brain 
lesions  may  coexist  with  spinal  fractures  and  complicate  the  problem. 

Fractures  of  the  atlas  and  axis  are  very  dangerous  because  they  are 
apt  to  involve  the  integrity  of  the  medulla  oblongata,  Avith  its  numerous 
nerve  centres,  and  are  above  the  roots  of  the  phrenic  nerves  which,  going 
to  the  diaphragm,  are  the  chief  respirator v  nerves.  If  cord  injury  occurs 
and  death  is  not  immediate,  the  paralysis  will  almost  certainly  involve 


FRACTURES    OF    THE    VERTEBRAE.  355 

the  trunk,  arms,  and  legs.  Fractures  below  the  axis  and  not  lower  than 
the  second  dorsal  vertebra  are  of  unfavorable  prognosis,  because  this  in- 
cludes the  roots  of  the  origin  of  the  phrenic  nerves  and  brachial  plexuses. 
The  phrenic  nerves  emerge  between  the  third  and  fourth  cervical  verte- 
brae, coming  from  the  fourth  cervical  pair  alone  or  having  accessory  roots 
from  the  third  and  fifth  cervical  nerves.  The  brachial  plexuses  are  de- 
rived from  the  fifth,  sixth,  seventh,  and  eighth  cervical  and  first  dorsal 
nerves.  Hence  injury  at,  or  no  higher  than,  the  fourth  cervical  vertebra  will 
involve  the  innervation  of  the  arms,  but  will  allow  the  functions  of  the 
phrenic  nerves  to  go  on  unless  intraspinal  hemorrhage  or  inflammation 
extends  above  the  level  of  the  fracture.  Lesion  of  the  cord  above  the 
fourth,  sufficient  to  induce  paralysis,  will  probably  involve  the  phrenics 
and  cause  death  pi'omptly  by  respiratory  failure  due  to  paralysis  of 
the  diaphragm.  When  the  other  muscles  of  respiration,  but  not  the 
diaphragm,  are  paralyzed,  the  character  of  breathing  is  peculiar.  In- 
spiration occurs  from  diaphragmatic  action  alone  and  expiration  from  the 
abdominal  walls  and  viscera  pressing  the  diaphragm  up.  Expiration 
is  consequently  passive  and  feeble ;  hence  the  patient  is  unable  to  talk, 
cough,  or  sneeze  forcibly  and  the  lungs  become  clogged  with  mucus. 
Change  of  posture,  by  changing  the  pressure,  may  alter  the  complexion 
of  symptoms. 

The  character  of  the  lesion  in  the  cord  determines  the  extent  and 
nature  of  the  symptoms.  Palsy  may  affect  one  or  both  arms  or  only 
certain  groups  of  muscles  in  the  upper  extremities.  So  the  phrenic  nerves 
may  be  slightly  involved  and  slow  the  movement  of  the  diaphragm  in- 
stead of  stopping  it  entirely  and  causing  immediate  death.  Slow  pulse, 
some  cyanosis,  delirium,  and  coma  may  be  observed  in  the  clinical  history 
of  fracture  of  the  cervical  vertebrae.  Irregularity  in  the  posterior  wall 
of  the  pharynx  may  be  observed  if  the  cervical  vertebral  bodies  are 
fractured  or  displaced.  The  paralysis  of  the  legs,  bladder,  and  rectum 
will  occur  in  a  manner  similar  to  what  is  observed  in  fractures  lower  in 
the  dorsal  region,  and  in  the  upper  lumbar  vertebrse. 

Prognosis. — In  spinal  fracture  accompanied  by  paralysis  the  prognosis 
is  unfavorable.  Many  cases  die  from  spinal  meningitis  and  myelitis 
and  from  the  exhaustion  of  bedsores  and  cystitis.  Cases  do  at  times  re- 
cover, but  usually  with  considerable  disability  from  loss  of  power  in  the 
legs  and  imperfect  control  of  the  bladder  and  rectum.  The  lower  the 
seat  of  fracture  the  better  the  chance  of  recovery  both  as  to  life  and  to 
function.  In  cases  which  finally  prove  fatal,  life  is  the  more  prolonged 
as  the  site  of  fracture  descends  the  spinal  column.  In  patients  who  finally 
recover  more  or  less  completely,  sensation  usually  returns  in  the  palsied 
region  before  motion. 

Treatment. — The  management  of  spinal  fracture  usually  resolves 
itself  into  catheterizing  the  bladder,  preventing  the  occurrence  of  bed- 
sores, and  treating  the  spinal  injury  and  inflammation  in  accordance  with 
the  rules  laid  down  in  the  section  on  Diseases  of  the  Nervous  System. 
The  patient  should  be  transported  and  turned  when  in  bed  with  great 
cai'e.  Especially  in  cervical  fracture  is  this  caution  important,  for  there 
unexpected  displacement  from  movement  is  more  liable  to  happen. 
Sudden  death  from  pressure  upon  the  medulla  may  be  thus  induced.  It 
has  been  suggested  in  fracture  of  the  neck  to  keep  the  patient  lying  on 
his  back  with  his  head  supported  in  a  hollow  made  in  a  bag  of  sand. 
In  fracture  lower  down  gypsum  jackets  have  been  applied  after  etherizing 
and  suspending  the  patient.     The   suspension  gives  an  opportunity   to 


350  DISEASES    AND    INJURIES    OF    BONES. 

reduce  the  fragments  by  extension  and  direct  jiressure,  and  the  jacket 
prevents  subsequent  displacement.  The  jacket  is  best  made  by  soaking 
at  one  time  several  sheets  of  gauze  cut  the  proper  shape,  in  a  paste  of 
gypsum  and  water,  and  applying  these  layers  around  the  trunk. 

If  disj)lacement  is  discoverable  and  paralysis  j)resent,  reduction  of  the 
displaced  fragments  by  means  of  extension,  rotation,  and  i)ressure  is  justi- 
fiable. Especially  is  this  so  because  of  the  freipient  impossibility  of  diag- 
nosticating dislocation  from  fracture. 

The  urine  should  be  drawn  with  a  soft-rubber  catheter  three  times  in 
the  twenty-four  hours,  beginning  as  soon  as  retention  occurs,  which  is 
usually  at  once.  The  surgeon  must  look  to  this,  for  the  patient  will 
feel  no  pain  from  the  distended  bladder.  The  dribbling  that  takes  place 
from  overflow  when  the  bladder  is  distended  to  its  utmost  may  deceive 
the  nurse,  who  will  think  the  urine  is  being  passed  incontinently.  This 
incontinence  of  retention  calls  for  catheterization.  Projjer  and  early  use 
of  the  catheter  delays  the  advent  of  cystitis.  When  true  incontinence 
occurs  the  catheter  is  no  longer  demanded.  When  cystitis  has  supervened 
the  bladder  should  be  washed  out  daily  or  every  other  day  with  warm 
water  passed  through  a  rubber  catheter  from  a  reservoir  held  a  foot  above 
the  patient's  abdomen.  The  solution  may  be  medicated  as  is  detailed 
in  the  section  on  Cystitis.  Spinal  fracture  rarely  gives  rise  to  pericystitis, 
pelvic  abscess,  or  sloughing  of  the  bladder  wall,  but  may  do  so. 

Bedsores  are  to  be  avoided  by  using  an  air-  or  water-bed  and  keeping 
the  patient  clean.  Careful  turning  to  change  the  points  of  pressure  is 
often  essential.  A  cheap  water-bed  can  be  made  by  filling  a  trough  with 
water  and  tacking  a  rubber  blanket  over  the  top. 

Trephining,  sawing,  or  cutting  away  the  arches  of  the  vertebrae  for  the 
purpose  of  removing  pressure  on  the  spinal  marrow  has  been  attended 
with  some  success,  and  should  be  adopted  more  frequently  than  has  here- 
tofore been  the  case.  To  a  great  extent  the  want  of  success  is  owing  to 
the  fact  that  the  injurious  pressure  is  often  caused  by  the  displacement  of 
the  vertebral  bodies,  which,  being  in  front,  are  not  easily  reached  ;  and  to 
the  circumstance  that  operative  interference  is  delayed.  Reduction  by 
extension  applied  to  the  patient's  shoulders  and  legs,  and  operative  relief 
of  spinal  cord  pressure  should  be  undertaken  immediately  after  the  receipt 
of  injury.  Perhaps  the  cord  may  at  times  suffer  pinching  by  a  temporary 
displacement  of  the  fragments  at  the  moment  of  accident.  In  such  cases 
operation  would  be  of  no  service,  because  the  bones  have  resumed  their 
normal  relations.  Operation  is  always  justifiable  if  the  fracture  is  definitely 
located  and  there  is  no  reason  to  suspect  irrelievable  displacement.  It 
mu.st  be  attempted  under  most  rigid  asepsis  or  antisepsis. 

Bromide  of  potassium,  cupping  and  ice  to  the  spine,  belladonna,  ergot, 
iodide  of  potassium,  strychnia,  massage,  counter-irritation,  and  electricity 
are  therapeutic  resources  to  be  employed  in  accordance  with  the  direc- 
tions given  under  the  treatment  of  Intraspinal  Inflammation. 

Fractures  of  the  Cranium. 

Pathology. — Cranial  fractures  differ  from  those  of  other  regions  in 
not  being  subject  to  displacement  from  muscular  action  ;  in  requiring 
no  retentive  apparatus  to  maintain  apposition  of  fragments,  and  in  having 
no  tendency  to  non-union.  Their  importance  and  interest,  moreover, 
centre,  not  in  the  damage  done  to    bone,  but  in  the  associated  injury 


FRACTURES    OF    THE    CRANIUM!.  357 

sustained  by  the  brain  and  its  membranes.  The  cerebral  injury  may 
be  contusion  or  laceration  due  to  the  same  force  that  broke  the  bone ; 
or  it  may  be  inflammation  and  irritation  occurring  secondarily  to  de- 
pression and  splintering  of  the  bone,  and  to  bacterial  infection  through 
the  fissures  in  the  bone,  or  to  overgrowth  of  callus  at  the  time  of 
repair. 

It  should  be  remembered  that  the  walls  of  the  cranium  consist  of 
two  tables,  separated  by  a  greater  or  less  amount  of  soft  and  vascular 
cellulated  bony  structure  called  the  diploe.  The  inner  table  is  nearly 
always  more  extensively  broken  than  the  outer,  because  the  fracturing 
force,  as  a  rule,  is  supplied  from  without  inward.  The  greater  shat- 
tering of  the  inner  table  is  especially  marked  in  comminuted  fractures. 
The  thinnest  parts  of  the  cranial  wall  are  in  the  orbital,  ethmoid,  squa- 
mous, and  inferior  occipital  regions.  The  frontal  region  is  remarkable, 
after  the  age  of  infancy,  for  the  existence  in  it  of  large  cavities,  the 
frontal  sinuses,  between  the  two  tables  of  bone. 

The  prognosis  in  cranial  fracture  is  favorable,  provided  the  brain  sus- 
tains no  primary  or  secondary  damage.  Under  opposite  conditions  death 
often  occurs.  Epilepsy  and  insanity  sometimes  follow  as  remote  results, 
especially  in  fractures  during  childhood. 

Union  is  rather  slow  because  the  callus  is  ^^^-  i^*!. 

furnished  by  the  osseous  tissue  rather 
than  the  external  periosteum  and  dura 
mater.  As  the  bony  tissue  is  not  very 
spongy  and  vascular,  the  amount  of  cal- 
lus is  small ;  hence  openings  left  by  re- 
moval of  fragments  or  after  trephining 
are  usually  closed  principally  by  fibrous 
tissue.  The  button  of  bone,  if  kept  asep- 
tic, may  be  replaced.  It  will  usually 
unite  with  the  surrounding  bone  and 
cause  bony  closure  of  the  opening.  The 
fracture  may  be  a  single  fissure  or  a  series  Repair  by  fibrous  tissue  after  tre- 
of  fissures  traversing  the  cranium  for  a  phiuing. 

great  distance,  even  running  across  sev- 
eral sutures.  There  is  in  such  cases  little  or  no  separation  or  displace- 
ment of  the  edges.  Separation  of  the  sutures  is  sometimes  caused  by  head 
injuries.  This  condition  is  practically  the  same  as  a  fracture.  Localized 
violence,  if  sufficient  to  cause  fracture,  gives  rise,  as  a  rule,  to  comminu- 
tion of  bone,  and  very  often  to  displacement.  This  displacement  is  gen- 
erally depression,  though  occasionally  elevation  of  a  fragment  may  be 
observed.  The  depressed  portion  may  be  attached  to  the  surrounding 
bone  along  a  part  of  its  margin,  thus  having  an  oblique  plane  ;  or  it  may 
be  driven  in  so  deeply  that  separation  of  its  entire  circumference  has 
occurred.  One  or  more  edges  may  be  locked  under  the  solid  bone.  Very 
frequently  the  edges  of  the  fragments  are  bevelled,  because  the  inner  table 
breaks  at  a  greater  distance  from  the  point  of  impact  than  the  outer. 
This  is  a  frequent  cause  of  interlocking,  and  of  consequent  difficulty  in 
elevating  the  depressed  piece.  A  few  cases  of  fracture  of  the  inner  table 
without  fracture  of  the  outer  have  been  recorded.  The  diagnosis  of 
such  cases  during  life  must  be  obscure,  unless  the  symptoms  of  brain 
disturbance  are  sufficiently  localized  to  justify  trephining.  Fractures  of 
the  outer  table  without  breaking  the  inner  may  be  produced  where 
the    bone   is  thick  by  any  force   only  sufficient  to  drive  the  fragment 


358  DISEASES    AXD    INJURIES    OF    BONES. 

into  the  soft  diploic  structure  between  the  two  tables.  In  children  per- 
manent depression  of  the  bone  may  occur  after  injury  without  actual 
fracture.  This  is  identical  with  what  has  been  described  as  bending  of 
bones  and  as  (rreen-siick  fracture.  It  is  probable  that  some  osseous 
fibres  at  least  are  torn.     Such  a  condition  in  the  adult  is  unknown. 

Symptoms. — Fractures  of  the  cranium,  whether  of  the  vault  or  base, 
show  no  special  rational  symptoms  that  may  not  arise  from  cerebral  con- 
tusion, laceration,  or  hemorrhage  without  fracture.  Marked  depression 
of  the  fragments,  liowever,  can  be  perceived  through  an  untorn  sealp  by 
palpation,  :xs  can  the  area  of  a  greatly  comminuted  fracture  which  feels 
soft  and  is  easily  depressed  by  the  finger  and  perhaps  shows  crej)itu.s. 
Local  subcutaneous  emphy.*ema  in  the  mastoid  region  is  diagnostic  of 
fracture  into  the  mastoid  cells.  A  translucent,  pulsatile  swelling  of  the 
scalp  is  indicative  of  escape  of  cerebro-spinal  fluid  from  the  ventricles  or 
subarachnoid  space,  and  is  conclusive  evidence  of  solution  of  continuity 
in  the  cranial  wall.  It  is,  however,  a  rare  phenomenon.  I.4iceration  of 
arteries  may  give  rise  to  large  fluctuating  tumors  under  the  scalp  without 
any  bone  injury  ;  but  these  are  not  translucent,  nor  as  a  rule  pulsatile. 
Depressed  fracture  is  often  stimulated  by  the  swollen  and  infiltrated  tis- 
sues forming  a  hard  ridge  alongside  of  a  softened  and  less  elevated  area 
of  scalp.  To  the  surgeon's  finger  this  condition  at  times  feels  identical 
with  a  ledge  of  bone  at  the  side  of  a  depressed  fragment.  It  must  also 
be  recollected  that  congenital  depressions  and  irregularities  from  old  inju- 
ries, periostitis,  and  senile  changes  may  exist.  When  a  wound  is  present 
the  diagnosis  is  easy,  fur  the  fissure  in  the  bone  is  easily  recognized  by  a 
red  line  due  to  the  blood  staining  the  crack.  This  must  not  be  confounded 
with  the  serrated  lines  shown  by  the  great  sutures,  and  the  sutures  around 
occasional  Wormian  bones.  If  the  outer  table  is  broken  the  inner  one 
seldom  escapes  similar  lesion.  Brain  tissue,  cerebro-spinal  fluid,  and 
blood  escaping  from  the  interior  of  the  skull  may  aid  in  establishing  a 
diagnosis  of  fracture.  Quite  profuse  venous  bleeding,  increasing  in  vol- 
ume during  expiration,  does  not  prove  that  a  meningeal  vessel  or  sinus 
has  been  torn,  for  it  may  come  from  the  vascular  diploic  bone  tissue. 
Fractures  of  the  base  of  the  cranium  can  rarely  be  seen  or  felt  by  the 
surgeon's  finger.  There  may  be  no  special  sign  of  the  injury.  At  times, 
however,  the  escape  of  brain  substance,  blood,  or  fluid  from  the  ear,  nose, 
mouth  or  orbit,  or  the  occurrence  of  paralysis  of  some  of  the  cranial 
nerves  may  serve  to  confirm  the  diagnosis. 

Bleeding  from  the  ear,  nose,  or  mouth  to  be  of  diagnostic  value  must 
be  profuse  and  continuous ;  since  limited  bleeding  occurs  from  damage  to 
the  soft  parts  in  these  regions.  The  appearance  of  blood  at  the  external 
orifices  of  the  head  after  laceration  of  an  intracranial  sinus,  arterv,  or 
vein,  is  due  to  fracture  of  the  bony  walls  of  these  cavities  and  rupture  of 
the  mucous  membrane.  In  escape  of  blood  from  the  ear  the  drum  mem- 
brane is  also  ruptured.  Sometimes,  when  the  petrous  portion  of  the  tem- 
poral bone  is  broken,  and  the  drum  membrane  not  injured,  the  blood 
passes  into  the  pharynx  by  way  of  the  Eustachian  tube,  to  escape  by  the 
mouth  or  nose,  or  to  be  swallowed  and  subsequently  vomited.  Marked 
extravasation  of  blood  under  the  conjunctiva  covering  the  eyeball,  espe- 
cially if  it  occur  a  day  or  more  after  the  head  injury,  and  it  does  not 
appear  in  the  eyelids  till  some  hours  later,  is  very  suggestive  of 
fracture  of  the  orbital  plate  of  the  frontal  or  sphenoid  bone.  Direct 
external  injury  to  the  eyeball  and  violent  vomiting  or  coughing  may 
also  give  rise  to  subconjunctival  ecchymosis.     So,  also,    may   fracture 


FRACTURES    OF    THE    CRAXIUM.  359 

of  the  malar  or  upper  maxillary  bone.  Signs  of  orbital  aneurism,  such 
as  protrusion  of  the  eyeball,  pulsation,  and  murmur,  suggest  the  occur- 
rence of  damage  to  the  internal  carotid  artery  or  the  cavernous  sinus  and 
make  fracture  of  the  cranial  base  probable.  The  late  occurrence,  after 
injury,  of  ecchymotic  spots  in  the  suboccipital  region  or  below  the  mastoid 
process  tends  to  confirm  the  diagnosis  of  basal  fracture. 

Discharge  from  the  ear  of  an  abundant,  colorless,  watery  fluid,  with 
little  accompanying  hemorrhage,  especially  if  it  occurs  promptly  after 
receipt  of  injury,  and  if  the  flow  is  modified  by  the  position  of  the  head 
and  by  coughing,  is  characteristic  of  fracture  of  the  petrous  bone  and 
laceration  of  the  tympanic  membrane.  It  is  cerebro-spinal  fluid  which 
will  be  found  highly  saline  and  almost  destitute  of  albumin.  The  escape 
of  Avatery  liquid  from  the  ear  under  other  circumstances  is  of  limited 
diagnostic  value.  It  may  be  the  liquid  of  Cotunnius  from  the  internal 
ear,  or  blood  serum  escaping  from  a  clot  in  the  oral  passages. 

Cerebro-spinal  fluid,  in  rare  instances,  may  escape  from  the  nose  or 
mouth  because  of  fracture  of  the  spheno-ethmoidal  portion  of  the  base, 
or  petrous  fracture  without  rapture  of  the  tympanic  membrane.  In  the 
latter  e\ent  the  intact  membrane  prevents  escape  from  the  auditory 
meatus  and  the  fluid  passes  into  the  phaiynx  by  the  Eustachian  tube. 
Escape  of  cerebro-spinal  fluid  or  abundant  hemorrhage  in  basal  fractures 
is  an  evidence  of  serious,  but  not  necessarily  fatal  injury. 

Paralysis  of  a  cranial  nerve  occurring  immediately  after  the  receipt  of 
a  head  injury  may  be  due  to  laceration  of  the  brain  near  the  origin  of 
the  nerve  or  to  hemorrhage  within  the  nerve  sheath.  It  is  very  suggestive, 
however,  of  fracture  of  the  base  with  synchronous  rupture,  contusion,  or 
compression  of  the  nerve  trunk.  The  pressure  may  arise  from  the  ex- 
istence of  displaced  bone  or  a  large  clot.  The  nerves  most  frequently 
subjected  to  such  conditions  in  basal  fracture  are  the  facial,  auditory, 
optic,  and  olfactory. 

Treatment. — There  has  been  until  recently  much  discussion  regarding 
the  proper  treatment  of  cranial  fractui^es.  Some  surgeons  opposed  oper- 
ative interference  in  the  great  majority  of  cases,  while  others  believed 
that  a  more  frequent  adoption  of  trephining  would  give  an  increased  ratio 
of  cures.  As  death  from  the  associated  or  induced  brain  lesion  is  common 
in  fractures  of  the  cranium,  it  is  certain  that  the  mortality  will  be  de- 
creased by  early  and  more  frequent  antiseptic  operations.  Elevation  and 
removal  of  bone  with  extraction  of  splinters  of  the  inner  table,  removal 
of  large  clots,  and  incision  even  of  the  dura  mater  would  avail  nothing  in 
cases  where  there  has  been  serious  contusion  or  laceration  of  the  interior  of 
the  brain  substance ;  but  many  cases  undoubtedly  die  because  peripheral 
lesions  immediately  adjacent  to  the  site  of  fracture  are  untreated  by 
mechanical  means  until  the  pathological  process  has  advanced  too  far  to 
be  remediable.  Fractures  of  the  base  are  amenable  to  but  little  operative 
treatment,  except  that  the  nasal  cavities  and  ears  should  be  made  aseptic 
and  plugged  with  gauze  impregnated  Avith  beta-naphthol,  carbolic  acid, 
or  iodoform.  The  general  treatment  is  identical  with  that  proper  in 
fractures  of  the  vault,  as  is  the  operative  treatment  when  the  lesion  is 
accessible. 

The  shock  following  head  injuries  is  to  be  met  by  recumbency  and  the 
measures  spoken  of  in  the  section  discussing  Concussion  and  Contusion  of 
the  Brain.  Care  must  be  taken  not  to  continue  a  stimulating  line  of 
treatment  after  reaction  has  fairly  begun,  because  the  danger  in  these 
cases  pertains  to  encephalitis,  which  is  a  possible  sequence  of  the  injury. 


360  DISEASES    AND    INJURIES    OF    BONES. 

As  soon  as  the  condition  of  shock  will  permit,  therefore,  elevation  of  the 
head,  cold  to  the  scalp,  low  diet,  perfect  quiet,  purgatives,  and  bromide 
of  potassium  (.^ij  to  3iv  in  twenty-four  hours)  should  be  insisted  upon. 
Alcoholic  stimulants  should  not  be  given  unless  the  primary  shock  is  pro- 
found, and  then  should  be  speedily  discontinued.  Shaving  the  entirfi 
scalp  is  a  wise  measure,  since  it  permits  more  accurate  examination  for 
scalp-wounds  and  cranial  depressions,  and,  in  addition,  renders  the  appli- 
cation of  cold  to  the  head  more  effective.  A  rublier  bag  or  bladder  rilled 
with  cracked  ice,  a  coiled  tube  with  cold  water  circulating  in  it,  or 
cloths  wet  with  ice-water,  are  ea.sy  methods  of  aj)plying  cold  to  the  scalp. 
If  ice  is  used,  a  degree  of  cold  sufficient  to  freeze  the  skin  might  be 
obtained  in  careless  hands.  Retention  of  urine  often  occurs,  and  recjuires 
the  use  of  the  catheter,  (xeneral  bloodletting  or  cupping  at  the  back  of 
the  neck  may  be  necessary  in  the  stage  of  infiamniation.  These  que.stions, 
however,  as  well  as  the  symptoms  of  traumatic  inflammation  of  the  brain, 
are  all  discussed  under  the  head  of  Encephalitis,  which  should  be  referred 
to  in  this  connection. 

Opinions  still  differ  somewhat  as  to  what  circumstances  render  it  justi- 
fiable to  convert,  by  incision,  a  closed  cranial  fracture  into  an  open  one, 
or  to  perforate  the  skull  by  trephine  or  saw  and  thus  expose  the  dura 
mater.  I  look  upon  incision  of  the  scalp  and  trephining  as  exploratory 
rather  than  therapeutic  measures.  In  many  instances  the  uncertainty  as 
to  the  cranial  lesion  is  more  dangerous  to  the  patient's  life  or  future 
health  than  the  conversion  of  a  closed  into  an  open  fracture  or  the  ex- 
posure of  the  encephalon  by  perforation  of  its  bony  wall.  Improved 
methods  of  wound  treatment  have  greatly  le.s.sened  the  risk  from  such 
operative  procedures,  but  encephalitis  is  as  fatal  as  ever.  The  symptoms 
denominated  "  compression  of  the  brain  "  are  probably  the  evidences  of 
encephalic  inflammation  rather  than  of  brain  compression.  As  this  in- 
flammation is  frequently  due  to  injury  from  spicules  of  the  inner  table  of 
the  bone,  to  irritation  from  intracranial  bleeding,  or  to  septic  infection,  I 
prefer  to  eliminate  by  operation  the  possibility  of  this  inflammation  being 
due  to  local  causes  under  the  seat  of  fracture. 

In  punctured  fractures  immediate  trephining  to  remove  the  depressed 
and  splintered  l>one,  to  sterilize  the  wound,  and  thus  to  avert  encephalitis, 
is  advised  by  all  authorities.  This  should  be  the  line  of  treatment,  even 
when  no  cerebral  symptoms  have  developed.  Punctured  fractures  are 
those  open  fractures  with  accentuated  depression  that  result  from  blows 
inflicted  by  the  corner  of  a  brick,  the  point  of  a  spike,  or  any  very  local- 
ized force  that  produces  a  puncture  of  the  cranial  wall  with  extensive 
splintering  and  driving-in  of  the  inner  table.  Gunshot  fractures  of  the 
cranium  are,  in  my  opinion,  to  be  treated  as  punctured  fractures. 

The  following  tabulated  statement  gives  my  views  concerning  the 
proper  treatment  of  cranial  fractures.  I  admit  that  it  is  more  heroic 
than  that  generally  taught,  but  it  has  been  written  only  after  careful 
consideration  of  the  reasoning  of  those  who  hold  the  opposite  opinion  to 
my  own.  Every  case  must  be  individually  studied,  and  the  patient's 
chances  of  death,  of  return  to  perfect  health,  and  of  life  with  subsequent 
epilepsy  or  insanity  carefully  weighed ;  but  for  a  working  rule  to  guide  the 
student  and  practitioner,  I  think  experience  will  show  the  indications 
given  in  the  table  to  be  correct.  Trephining,  properly  performed,  is  in 
itself  so  free  of  danger  that  in  a  doubtful  case  the  patient  had  better  be 
trephined  than  allowed  to  run  the  risk  of  death,  epilepsy,  or  insanity. 


FRACTURES  OF  THE  CRANIUM. 


361 


Syllabus  of  Treatment  of  Cranial  Fractures. 


r  1- 

2. 

Without  evident  depression 

Without  brain  symptoms. 
With 

No  operation. 

Incise  scalp  and    tre- 

Closed fissured  frac 
tures. 

3 

4. 
L 

With              "              " 

Without      " 
With 

phine. 

Incise  scalp  and  pos- 
sibly trephine. 

Incise  scalp  and  tre- 
phine. 

Closed  comminuted 
fractures. 

^  5. 
6. 

8. 

Without         "               " 

With 

Without       "             " 
With             "             " 
Without       "             " 

With        •    " 

Incise  scalp  and  prol- 
ably  trephine. 

Incise  scalp  and  tre- 
phine. 

Incise  scalp  and  tre- 
phine. 

Incise  scalp  and  tre- 
phine. 

Open  fissured  frac-  -^ 
tures. 

'   9. 

10. 
11. 
12. 

Without        "              " 
With 

Without       "             " 

With            " 
Without       "              " 
With 

No     operation,     and 

treat  wound. 
Trephine. 
Posslblj'  trephine. 
Trephine. 

Open    comminuted  _ 
fractures. 

'13. 
14. 
15. 
16. 

Without        "               " 
With              "               " 

Without       "              " 

With 

Without      " 

With             "              " 

Probably  trephine. 
Trephine. 
Trephine. 
Trephine. 

Punctured  and  gun- 1 
shot  fractures.       J 

17. 

In  all  cases  .... 

.    Trephine. 

In  classes  3  and  11  I  should  be  inclined  to  trephine  if  the  depression 
was  marked  or  the  fissures  sufficiently  multiple  to  approach  the  character 
of  a  comminuted  fracture. 

In  classes  5  and  13  I  should  trephine  unless  the  comminution  was 
found  to  be  inconsiderable. 

Operation,  when  decided  upon,  should  be  performed  at  once  or  certainly 
not  delayed  more  than  a  few  hours.  All  cases,  whether  trephined  or  not, 
should  be  treated  as  cases  of  incipient  encephalitis. 

When  careful  study  of  the  paralytic  and  other  symptoms  accompany- 
ing head  injuries  localizes  the  cerebral  lesion  near  the  seat  of  contusion 
of  the  scalp,  incision  is  to  be  resorted  to  promptly,  even  if  there  is  only 
a  suspected  fracture.  If  no  fracture  is  found  trephining  should,  as  a  rule, 
be  performed,  because  it  is  probable  that  a  hemorrhage  has  occurred  either 
between  the  bone  and  dura  mater  or  under  the  dura  mater.  Trephining 
will  permit  the  surgeon  to  remove  this  source  of  trouble  if  outside  the 
dura  mater;  if  absence  of  pulsation  or  change  in  color  of  the  dura  mater 
is  observed  he  should  incise  that  membrane  in  the  expectation  of  finding 
a  clot  beneath  it. 

The  study  of  cerebral  localization  should  be  cultivated  by  all  surgeons, 
for  many  cases  of  head  injury  would  be  treated  much  more  successfully 
than  is  usually  the  case  if  the  neurologist  and  surgeon  employed  their 
skill  in  combination.  The  symptoms  and  cranial  lines  by  which  neurolo- 
gists locate  brain  lesions  have  been  referred  to  in  the  section  on  Encephal- 
itis, Avhich  should  be  read  in  this  connection.  Incision  of  the  dura  mater, 
aspiration  of  the  brain  substance,  and  the  excision  of  brain  tumors  will 
become  less  unusual  when  all  surgeons  are  familiar  with  the  principles  of 
cerebral  localization.^  In  fracture  of  the  cranium  trephining  is  sometimes 
demanded  by  the  paralytic  and  other  symptoms  localizing  the  lesion 
under  the  seat  of  fracture,  when  the  amount  of  damage  seen  in  the  skull 
would  lead  one  to  abstain  from  operation.  Hence  cognizance  of  the  sig- 
nificance of  local  palsies  and  spasms  is  demanded  of  the  skilled  surgeon. 


1  See  Operative  Surgerv  of  the  Human   Brain,  bv  John  B.Roberts.     P.  Blakiston  & 
Co.,  1885. 


362 


DISEASES    AND    INJURIES    OF    BONES. 


TiM:i'HiMN(i. — Perforation  of  the  cranium  sliouJd  usually  be  done  by 
means  of  a  slightly  conical  trephine,  which  is  safer  than  the  cylindrical 
in^^trumeut,  except  in  the  hands  of  one  familiar  with  the  operation.  Holes 
of  various  shapes  can  readily  be  made  by  the  flat-face  burr  of  the  surgical 
engine,  but  this  apparatus  is  not  always  obtainable.     Holes  of  any  shape 


Fio 


'  Hopkins's  gnawing  forceps. 

and  size  can  be  made  by  enlarging  a  small  trephine  cut  with  the  gnawing 
forceps.  Since  the  usual  object  in  cases  of  fracture  is  to  get  an  opening 
through  which  to  insert  an  elevator  to  pry  up  the  depressed  fragments,  a 
small  trephine  should  be  employed.  One  not  over  three- eighths  of  an 
inch  in  outside  diameter  at  the  cutting  edge  is  large  enough.     In  opera- 


FiG.  158. 


Author's  asejitic  tit-jiliine. 

tions  for  removing  brain  tumors  a  trephine  of  one  and  a  half  to  two 
inches  in  diameter  may  be  used.  After  the  induction  of  anaesthesia,  the 
incision  in  the  scalp  should  be  made  of  a  horseshoe  shape,  with  its  con- 
vexity downward  when  the  patient  is  recumbent,  so  that  during  the  after- 
treatment  the  drainage  may  be  free.  If  a  wound  previously  exists  it  may 
be  enlarged  by  a  conical  incision,  though  the  horseshoe  flap  affords  better 


FRACTURES  OF  THE  CRANIUM, 


363 


Fig.  159. 


exposure  and  should  be  made  if  the  shape  and  position  of  the  wound  will 
permit.  The  knife  should  divide  the  scalp  and  periosteum  at  the  same 
time  in  order  that  all  the  soft  structures  may  be  raised  in  one  layer.  If 
any  periosteum  remains  attached  at  the  seat  of  operation  it  should  be 
pushed  back  with  the  knife  handle. 

In  trephining  for  epilepsy,  cerebral  abscess  or  tumor  the  periosteum 
need  not  be  removed  except  at  the  point  where  the  crown  of  the  trephine 
is  applied.  Indeed  a  circular  incision  in  it  the  size  of  the  disk  to  be  re- 
moved is  all  that  is  needed.  When  the  aseptic  button  of  bone  is  to  be 
replaced  in  the  gap  the  periosteum  upon  its  upper  surface  may  then  be 
utilized  for  holding  sutures  passed  through  it  and  then  through  the  peri- 
osteum at  the  margin  of  the  opening. 

The  crown  of  the  trephine  should  be  placed  on  the  bone  perpendicu- 
larly to  its  surface,  but  before  its  application  the  centre-pin  of  the  trephine 
must  be  protruded  about  one-sixteenth  of  an  inch.  In  fractures  the  in- 
strument must  be  placed  on  solid  and  undepressed  bone  with  about  one- 
third  of  the  crown  overlapping  the  portion  to  be  elevated.  If  the  latter 
precaution  is  not  observed,  a  bridge  of  solid  bone  will  be  left,  which  will 
prevent  the  application  of  the  elevating  lever.  Elevation  and  extraction 
are  often  facilitated  by  removing  a  disk  at  the  least  depressed  edge  of  the 
depressed  fragment.  The  trephine  should  be  semi-rotated  from  left  to 
right  and  right  to  left,  with  moderate  pressure  against  the  bone.  As  soon 
as  the  groove  is  made  sufficiently  deep  to  maintain  the  cutting  edge  in 
position,  the  centre-pin  is  retracted  lest  it  should  perforate  the  inner  table 
and  membranes.  The  trephine  is 
then  reapplied  and  the  groove  cau- 
tiously deepened.  When  blood  begins 
to  flow  it  is  evident  that  the  diploic 
structure  is  being  cut  by  the  sawing 
edge,  and  additional  care  must  be 
exercised,  since  the  inner  table  is 
thin.  In  some  skulls,  how^ever,  the 
diploe  is  practically  absent.  After 
a  few  more  half-turns  have  been 
made  the  trephine  is  removed,  and 
the  depth  of  the  groove  ascertained 
by  carrying  along  it  the  point  of  a 
probe  or  pin.  If  the  skull  is  of  un- 
even thickness,  as  shown  by  the  cran- 
ial wall  being  completely  divided  in 
one  segment  of  the  circle  and  not  in 
the  remainder,  the  trephine  must  be 
tilted  toward  the  uncut  side  and  cau- 
tiously rotated,  or  a  segment  trephine 
may  be  used.  Very  soon  the  disk 
is  found  to  be  loose,  and  is  readily 
picked  or  tilted  out  by  forceps  or 
elevator.  If  the  Roberts's  aseptic 
trephine  is  employed  there  is  less 
danger  of  sepsis  because  there  is  no 
centre-pin  tube  to  retain  bacteria.  The  disk  is  then  dropped  out  of  the 
crown  instead  of  retracting  the  pin  when  a  groove  is  cut. 

The  point  of  an  elevator  is  then  pushed  under  the  depressed  fragment, 
and  used  as  a  lever  to  raise  the  bone  into  place.     Loose  pieces  and  spicules 


Author's  segment  trephine. 


3H4:  DISEASES    AND    INJURIES    OF    BONES. 

of  bone  are  removed  by  the  elevator  or  forceps  ;  but  care  must  be  observed 
not  to  twist  during  extraction  a  large  and  interlocked  fragment  so  as  to 
lacerate  the  dura  mater.  It  is  better  to  saw  away  the  ledge  or  point  of 
bone  interfering,  or  even  to  make  a  second  trephine  hole.  There  is 
usually  in  comminuted  fractures  one  piece  that  acts  as  a  keystone;  when 
this  is  removed  or  elevated,  the  other  fragments  are  readily  managed.  The 
Hey's  saw  and  gnawing  forceps  do  good  service  in  cutting  away  corners 
of  bone.  Spicules  driven  into  the  membranes  or  brain  should  be  searched 
for  with  the  finger,  and  at  once  removed.  Finally,  all  sharp  edges  of 
bone  should  be  trimmed  away,  the  wound  washed  with  sublimate  solution, 
a  drain  of  catgut  or  rubber  tube  inserted,  the  scalp  flaps  sutured  in 
position,  and  the  gauze  dressing  applied.  No  metallic  j)late  is  ever  used 
after  trephining.  The  bone  wound  closes  usually  by  fibrous  tissue,  the 
scalp  wound  healsasdoother  wounds  of  the  soft  parts.  It  is  common  now 
to  replace  all  or  some  of  the  fragments  of  bone,  in  order  that  they  may 
aid  in  closing  the  gap  in  the  skull,  by  furnishing  osseous  tissue  and  in- 
ducing ossific  deposition  in  the  granulation  tissue. 

To  accomplish  this  successfully,  it  is  necessary  that  the  fragments  taken 
out  be  thoroughly  cleaned  in  an  antiseptic  solution,  of  a  temperature  of 
about  105°  F.,  and  then  kept  warm  in  a  similar  antiseptic  lotion,  or 
between  warm  antiseptic  cloths,  until  the  moment  before  the  flaps  are  to 
be  sutured.  The  bony  fragments  are  then  laid  loosely  upon  the  dura 
mater  and  covered  by  the  scalp  tissues.  This  procedure  is  most  successful 
in  exploratory  operations,  because  then  there  is  less  probability  of  the 
grafts  being  septic. 

Incision  of  the  dura  mater,  hypodermic  puncture  of  the  brain,  or  even 
incision  of  abscess  in  the  brain,  does  not  alter  the  method  of  procedure, 
so  far  as  the  preliminaiy  trephining  and  after-dressing  are  concerned. 
The  dura  should,  however,  be  sutured  with  catgut  if  large  incisions  have 
been  made  in  it.  The  bone  grafts  can  then  be  laid  upon  it;  but  provi- 
sion should  be  made  for  removal  of  serous  exudations  and  blood  by 
drainage.  The  drainage  tube  or  threads  may  be  removed  in  thirty-six 
hours,  if  the  wound  is  aseptic. 

If  it  is  possible  to  avoid  doing  so,  the  trephine  should  never  be  applied 
over  the  superior-longitudinal  sinus,  the  lateral  sinus,  the  torcular 
Herophili,  or  the  middle  meningeal  artery  where  it  grooves  the  anterior- 
inferior  angle  of  the  parietal  bone.  Hemorrhage  from  wounding  these 
structures  may  prove  very  serious. 

The  removal  of  comminuted  bone,  however,  may  lay  open  these  vessels. 
Bleeding  from  the  artery  may  be  arrested  by  ligation,  by  forcing  a  piece 
of  wood  into  the  bony  canal,  if  there  is  one,  or  by  seizing  the  vessel  and 
the  bone  in  a  pair  of  spring  forceps,  which  can  be  left  in  position  for 
several  hours.  Hemorrhage  from  the  venous  sinuses  may  at  times  be 
controlled  by  forcing  a  little  pad  of  absorbent  gauze  or  sponge  between 
the  vessel  and  the  overlying  solid  bone.  Ligatures  or  a  suture  carried 
around  the  bleeding  vessel  by  means  of  a  needle  should  be  tried  when  the 
hemorrhage  persists.  Trephining  over  the  sinus,  at  a  point  a  little  distance 
from  the  wound,  might  be  required  to  enable  the  surgeon  to  apply  such  a 
suture;  but  this  event  must  be  exceedingly  rare.  Hemostatic  forceps 
may  be  left  in  situ  until  the  first  dressing  is  changed.  In  trephining  over 
the  air-cells  in  the  frontal  bone,  called  the  frontal  sinuses,  a  large  trephine 
should  be  used  to  i)erforate  the  outer  table,  and  a  smaller  one  to  bore 
through  the  inner. 


FRACTUEE  OF  THE    NASAL    BONES    AND    CARTILAGES. 


865 


Fractures  of  the  Bones  of  the  Face. 

Fractures  of  the  facial  bones  are  usually  the  result  of  great  direct 
violence  ;  hence  several  of  the  bony  components  of  the  face  may  be  broken 
by  the  same  injury.  Owing  to  the  great  vascularity  of  the  parts,  union 
takes  place  quickly  and  with  the  formation  of  but  little  callus.  It  is  im- 
proper to  remove  splinters  of  bone  which  seem  to  have  but  slight  attach- 
ment, for  necrosis  of  such  pieces  is  uncommon. 


Fracture  of  the  Nasal  Bones  and   Cartilages. 


Injuries  of  the  nose  producing  fracture  may  involve,  in  addition  to  the 
nasal  bones,  the  nasal  processes  of  the  superior  maxilla,  the  frontal  spine,  and 
the  perpendicular  plate  of  the  ethmoid  upon  which  the  nasal  bones  are 
supported.  The  cartilaginous  septum  is  often  bent  or  broken,  and  the 
lateral  cartilages  may  sustain  similar  lesions,  or  be  torn  loose  from  the 
lower  end  of  the  nasal  bones.  The  vomer  likewise  may  be  broken.  It 
is  said  that  fracture  of  the  cribiform  plate  of  the  ethmoid  may  accom- 
pany fracture  of  the  nasal  bones.  I  can  scarcely  conceive  of  this  occur- 
ring, unless  the  force  was  violent  enough  to  cause  fracture  first  of  the 
frontal  bone.  Such  instances  are  properly  considered  and  treated  as 
fractures  of  the  cranium.  In  young  children  the  arch  made  by  the  junc- 
tion of  the  two  nasal  bones,  may,  it  is  said,  be  flattened  from  the  suture 
opening  on  the  posterior  aspect.  Blows  received  directly  on  the  top  of 
the  nasal  bridge  would  have  this  tendency. 

Fractures  of  the  nose  are  often  comminuted,  and  attended  w-ith  much 
swelling.  The  swelling,  which  rapidly  appears,  is  liable  to  conceal  the 
displacement,  interfere  with  accurate  diagnosis,  and  obstruct  nasal 
respiration.  Congenital  deviations  of  the  sej)tum  may  deceive  the 
surgeon.  Emphysema  of  the  face  may  occur  from  air  escaping  into  the 
subcutaneous  cellular  tissue  daring  efforts  at  blowing  the  nose  soon  after 
the  injury.  This  sym^^tom  needs  no  treatment.  Some  suppuration  often 
occurs,  because  the  mucous  membrane  is  torn  and  bacteria  get  access  to 
the  wound  from  the  nasal  chambers.  Caries  and  necrosis  are  rather  un- 
usual, but  may  occur.  Union  generally  takes  place  rapidly,  and  is  com- 
plete within  two  or  three  weeks.  If  the  fracture 
extends  into  the  nasal  processes  of  the  superior 
maxilla,  the  lachrymal  duct  may  become  occluded 
by  the  displacement  or  by  callus. 

The  risk  of  permanent  disfigurement  is  so  great 
and  union  occurs  so  soon  that  careful  examination 
and  replacement  should  be  instituted  promptly, 
and,  if  necessary,  under  an  anaesthetic.  If  the 
nasal  bones  are  depressed,  a  narrow  and  rigid  in- 
strument, such  as  a  grooved  director,  passed  into 
the  nostril  will  probably  enable  the  surgeon  to  ele- 
vate the  fragment.  When  there  is  a  tendency  for 
the  depression  to  recur,  a  steel  pin  or  needle  may 
be  thrust  through  the  nose  from  right  to  left  under- 
neath the  broken  bone.  A  strip  of  rubber  or  adhesive  plaster  carried 
across  the  dorsum  of  the  nose  is  then  attached  to  the  ends  of  the  needle. 
Perforated  shot  may  be  clamped  upon  the  ends  of  the  pin  to  prevent 


Fig.  1 


Author's  method  of  pin- 
ning nasal  septum. 


3G6  DISEASES    AND    INJURIES    OF    BONES. 

spreading  and  tlatteuing  of  the  nasal  bridge.  It  is  well  to  place  a  small 
disk  of  rubber  on  the  pin,  between  the  skin  and  the  shot,  to  prevent  ulcera- 
tion and  to  maintain  elastic  compression.  The  pin  should  remain  in  position 
for  about  ten  days.  When  a  tendency  to  displacement  of  the  cartilaginous 
portion  of  the  nose  is  present,  the  proper  conformation  should  be  main- 
tained by  transfixing  the  cartilages  with  pins,  and,  by  a  sort  of  leverage 
action,  pinning  them  in  place.  I  have  found  this  method  effectual,  after 
incising  the  deformed  curtilage  in  cases  of  nasal  deformity  from  fractures 
received  many  years  previous  to  operation.'  Plugs  and  canulas  in  the 
nostrils  are  uncomfortable,  unnecessary,  and  inefficient.  Cooling  lotions 
may  be  applied  to  the  fractured  nose,  if  there  are  much  pain  and  swelling. 
Patients  should  be  cautioned  against  violently  blowing  the  nose  or  snuffling, 
for  displacement  may  thus  be  caused. 

If  profuse  hemorrhage  occurs,  the  nostril  on  the  bleeding  side  should 
be  plugged.  The  method  recommended  by  Dr.  R.  J.  Levis  is  the  simplest 
and  best.  To  the  end  of  a  strong  string,  about  eight  inches  long,  a  disk 
of  moistened  sponge,  about  three-fourths  of  an  inch  in  diameter  and  three- 
eighths  of  an  inch  in  thickness,  is  firmly  tied.  This  sponge  is  oiled,  and, 
by  forceps,  pushed  into  the  nostril  and  along  its  floor  till  it  reaches  the 
posterior  nares.  Upon  the  string  hanging  from  the  anterior  nostril  four 
or  five  similar  disks  of  sponge  are  strung  by  central  holes  like  beads,  and 
consecutively  crowded  into  the  nose  until  the  cavity  is  filled.  After  the 
lapse  of  twenty-four  hours  the  disks  are  removed  one  by  one.  This 
method  is  much  better  than  that  accomplished  by  means  of  Belloccfs 
canula,  and  is  applicable  to  idiopathic  as  well  as  traumatic  bleeding. 

Fracture  of  tlip  Mular  Bone  and  Zygoma. 

These  rare  injuries  are  readily  recognized  by  the  deformity  and  the 
irregular  outline,  which  can  be  felt  by  the  fingers.  If  fracture  of  the 
malar  bone  extends  into  the  floor  of  the  orbit,  the  superior  maxillary 
nerve  may  be  injured,  subconjunctival  ecchymosis  appear,  or  protrusion  of 
the  eyeball  from  intra-orbital  hemorrhage  take  place.  In  fracture  of  the 
zygomatic  arch  the  mouth  may  not  open  freely,  because  the  displaced 
fragments  obstruct  the  movement  of  the  coronoid  process  of  the  lower 
jaw.     Pain  and  swelling  sometimes  simulate  or  increase  this  disability. 

The  treatment  consists  in  replacement  by  pressure  of  the  fingers  upon 
the  cheek  or  within  the  mouth.  If  necessary,  an  incision  may  be  made 
for  the  introduction  of  a  lever  under  the  displaced  bone,  or  a  screw  may 
be  fastened  into  the  bony  surface  and  used  to  pull  the  fragment  upward. 

Fr(icture!<  of  the  Superior  Maxillary  Bone. 

The  alveolar,  nasal,  and  other  processes  of  the  upper  jaw  bone  are  the 
parts  that  most  frequently  sustain  fracture.  Even  these  injuries  are 
uncommon,  except  fracture  of  the  alveolar  process  during  the  extraction 
of  teeth.  The  lachrymal  canal,  the  orbit,  and  the  superior  maxillary 
nerve  may  be  involved  in  the  injury,  with  results  similar  to  those  de- 
scribed above  under  nasal  and  malar  fractures.  Union  occurs  in  three 
or  four  weeks.  Separation  of  the  suture  between  the  two  superior  max- 
illaries  has  been  observed. 

1  See  Cure  of  Crookeil  and  Otherwise  Deformed  Noses,  by  John  B.  Roberts.  Phila.,  1889. 


FRACTURE    OF    THE    INFERIOR    MAXILLARY    BONE.      367 


Fig.  161. 


Gunning's  inter-dental  splint,  with, 
opening  for  introducing  food. 


Examination  of  the  surface  of  the  face  and  of  the  interior  of  the  mouth 
will  disclose  the  nature  of  the  lesion.  In  treating  such  fractures  loose 
teeth  should  be  left  in  place,  for  they  frequently  become  firmly  fixed 
again.  Apposition  can  sometimes  be  maintained  by  keeping  the  teeth  of 
the  lower  jaw  firmly  closed  against  those  of  the  upper  by  means  of  Bar- 
ton's bandage  or  a  band  of  adhesive  plas- 
ter passed  under  the  chin  with  its  ends 
crossed  at  the  top  of  the  forehead.  Wiring 
the  teeth  adjoining  the  line  of  fracture  is 
sometimes  a  good  means  of  preventing 
motion. 

The  inter-dental  splint,  which  is  a  mould 
of  gutta  percha  or  similar  plastic  material 
made  to  fit  the  grinding  surfaces  of  the 
teeth  of  both  jaws,  will  in  most  instances 
act  sufficiently.  It  is  placed  in  position, 
and  the  mouth  kept  shut  by  bandaging  or 
adhesive  plaster.  Cork  cut  to  fit  the  teeth 
in  the  same  manner  w'ill  answer  a  good 
purpose  if  no  dentist  is  at  hand  to  make 
the  more  complicated  apparatus.  During 
the  three  weeks  that  closure  of  the  mouth  is  enforced,  liquid  food  is 
introduced  through  the  crevices  between  the  teeth  or  by  a  tube  passed 
between  the  alveolar  arch  and  cheek  as  far  back  as  the  last  molar.  Inter- 
dental splints  may  be  made  thick  enough  to  have  a  perforation  for  this 
purpose. 

Frachire  of  the  Inferior  Maxillary  Bone. 

The  lower  jaw  is  more  frequently  broken  than  any  other  bone  of  the 
face.  The  seat  of  fracture  is  generally  toward  the  anterior  part  of  the 
body  of  the  bone.  Fracture  of  the  ramus  is  comparatively  rare,  and 
fracture  of  the  condyle  and  coronoid  process  even  more  unusual.  The 
body  of  the  bone  is  said  to  be  weaker  and  more  easily  broken  near  the 
root  of  the  canine  tooth  and  the  mental  foramen  than  elsewhere.  Loss 
of  teeth  and  consequent  atrophy  of  the  alveolar 
process  may  reduce  the  normal  strength  of  the  -piG.  162. 

bone  in  other  situations,  and  be  the  predisposing 
cause  of  fracture.  The  most  frequent  seat  of 
fracture,  according  to  Gurlt's  statistics,  is  near 
the  middle  line  in  front.  These  statements 
exclude  from  consideration  mere  splintering  of 
the  alveolar  process  often  produced  by  pulling 
teeth  and  by  other  causes.  Double  fracture  of 
the  lower  jaw  is  not  uncommon. 

When  the  body  of  the  bone  is  broken  the 
fracture  often  communicates  wdth  the  mouth 
through  a  tear  of  the  gum.  The  fracture  be- 
comes in  such  cases,  therefore,  an  open  one,  and 
is  accompanied  by  suppuration  because  it  can- 
not be  kept  aseptic.  Suppuration  is  usually 
not  very  great,  for  drainage  is  free.     The  close 

attachment  of  the  fibrous  tissue  of  the  gum  to  the  alveolus  is  a  sufficient 
explanation   of  this  frequent  complication.     The   inferior  dental    nerve 


Fracture  of  lower 
teeth. 


iaw  behind 


368 


DISEASES    AND    INJURIES    OF    BONES. 


may  be  torn  or  bruised  when  its  canal  is  involved  in  the  fracture.  An- 
les^thesia  of  the  correspondintr  half  of  the  lower  lip  and  chin  is  the  result 
of  this  norve  lesion. 

The  displacement  and  unnatural  mobility  in  fracture  of  the  body  are 
easilv  detected,  but  the  surgeon  must  bear  in  mind  the  possibility  of  mal- 
positions of  the  teeth  from  irregular  development  and  irruption.  In  single 
fracture  of  the  body  away  from  the  median  line  the  anterior  fragment  is 
apt  to  be  displaced  inward  toward  the  mouth.  In  double  or  bilateral 
fracture  of  the  body  the  middle  or  chin  portion  may  be  drawn  downward 
by  muscular  action.  The  displacement  in  fracture  of  the  ramus  is  more 
difficult  of  detection,  but  may  often  be  recognized  with  the  finger  in  the 
mouth. 

Pain,  often  increased  by  motion  or  deglutition,  and  excessive  secretion 
from  the  mouth  are  observed  in  fracture  of  the  lower  jaw.  Perhai)s  the 
increa.«e  of  saliva  and  mucus  is  largely  apparent,  the  excess  observed 
being  really  due  to  a  want  of  proper  control  of  these  fluids  within  the 
mouth.  Fetor  from  decomposing  food,  pus,  and  other  secretions  is  often 
marked.  Abscesses  about  necrosed  pieces  of  bone,  fistulous  tracts,  and 
ulceration  of  the  mucous  membrane  may  add  to  the  discomfort  of  the 
patient,  who  perha})s  becomes  greatly  debilitated  by  swallowing  foul  secre- 
tions and  being  deprived  of  a  fully  nutritious  diet. 

Union  of  ordinarv  fracture  of  the  jaw  takes  place  in  five  or  six  weeks. 
The  prognosis,  even  in  bad  cases,  is  ultimately  good.  Even  if  teeth  are 
lost  tlie  solid  union  which  occurs  gives  a  good  basis  for  the  adaptation  of 
artificial  teeth. 


Fig.  163. 


Fh;.  1()4. 


Barton's  bandage  for  fracture 
of  jaw. 


Garretson's  modification  of  Barton's  Ijandaare. 


Reduction  of  the  fracture  by  pressure  of  the  fingers  on  the  teeth  is 
usually  easy,  though  occasionally  comminuted  fragments  or  displaced 
teeth  may  cause  interlocking  and  require  removal  before  correct  apposi- 
tion is  obtainable.  Teeth  which  are  simply  loosened  should  not  be  pulled 
unless  they  impede  reduction.  Tenotomy  of  displacing  muscles  is  rarely 
necessary.  The  normal  relation  of  the  upper  and  lower  teeth  in  most 
mouths  is  that  the  upper  incisors  come  in  front  of  the  lower  when  the 
mouth  is  quietly  closed.  This  should  be  recollected.  Generally  there  is 
little  tendency  to  displacement  after  ten  days  have  passed.     Hence  after 


FRACTURE    OF    THE    INFERIOR    MAXILLARY    BONE.      369 

the  lapse  of  about  three  weeks  the  dressings  may  be  removed,  and  the 
patient  given  an  opportunity  to  attempt  mastication  cautiously  in  order 
to  demonstrate  whether  the  fragments  have  been  adjusted  in  a  manner  to 
give  the  best  use  of  the  teeth  in  chewing.  Any  slight  change  in  adjust- 
ment is  then  possible,  for  consolidation  will  not  be  complete.  After  re- 
duction uncomplicated  fractures  of  the  jaw  are  to  be  treated  by  keeping 
the  upper  and  lower  teeth  in  contact  by  means  of  the  Barton  figure-of- 
eight  bandage  of  the  occi^Dut  and  chin.  The  mouth  must  be  cleansed 
with  disinfectant  washes  of  carbolic  acid  or  beta-naphthol,  tincture  of 
myrrh  (ttlxv  to  f5J  of  water)  and  similar  drugs.  Feeding,  as  in  fracture 
of  the  upper  jaw,  is  accomplished  by  introducing  milk  and  soups  through 
the  crevices  between  the  teeth,  or  by  a  tube  passed  behind  the  last  molar 
or  through  the  nostril.  The  hair  and  beard  of  men  should  be  closely  cut 
before  these  bandages  are  aj^plied ;  otherwise  they  are  apt  to  slip  or  be 
very  uncomfortable. 

When  the  simple  bandage  does  not  give  sufficient  firmness  to  cause 
maintenance  of  correct  apposition,  or  when  the  lateral  pressure  of  the 
bandage  causes  overriding,  it  is  well  to  adapt  a  moulded  splint  to  the  out- 
side of  the  chin.  Pasteboard,  felt,  leather,  gutta  percha,  or  gauze  stiffened 
with  gypsum  are  the  proper  materials  from  which  to  construct  a  hollow 
cap  to  fit  the  front  and  lower  surface  of  the  chin.  The  splint  should  ex- 
tend on  each  side  nearly  as  far  back  as  the  angle  of  the  jaw ;  and  may 
need  a  crescentic  portion  of  its  posterior  edge  cut  away  in  order  to  avoid 
pressure  on  the  throat  above  the  larynx.  The  splint  is  padded  and  placed 
over  the  chin  and  held  in  position  by  the  bandage.  Before  applying  the 
bandage,  the  splint  may  be  fixed  in  position  by  carrying  a  band  of  rubber 
adhesive  plaster  over  the  splint  and  as  high  up  on  the  cheeks  as  the 
zygoma. 

Fig.  165.  Fig.  166. 


Original  shape  of  gutta  percha  or  pasteboard.  Gutta-percha  splint  moulded  to 

fit  chin. 

If  the  tendency  to  displacement  is  persistent,  wiring  the  fragments 
together  or  some  form  of  interdental  splint  becomes  necessary.  A  strong 
silver  or  iron  wire  may  be  fastened  around  several  teeth  on  each  side  of 
the  fracture ;  or  in  open  fractures  the  ends  of  the  bone  may  be  drilled 
and  wire  sutures  passed  through.  Interdental  splints  are  splints  worn 
inside  the  mouth  and  so  fitted  to  the  teeth  and  alveolus  that  motion  at 
the  seat  of  fracture  is  prevented.  An  impression  of  the  teeth  and  alve- 
olus is  taken  while  the  fragments  are  held  in  position.  By  means  of  this 
impression  a  splint  of  metal  or  vulcanized  rubber  is  constructed  which 
contains  indentations  into  which  the  teeth  accurately  fit.  If  such  a  splint 
is  applied  to  the  teeth  of  the  broken  jaw  and  fixed  so  that  the  jaw  bone 
is  kept  continually  in  close  contact  with  it  motion  at  the  seat  of  fracture 
is  impossible,  because  the  ci'owns  of  the  teeth  are  buried  in  indentations 
on  the  surface  of  the  splint.     There  are  several  methods  of  securing  the 

24 


370  DISEASES    AND    INJURIES    OF    BONES. 

splint  to  the  jaw.  Probably  the  best  is  to  have  the  upper  surface  of  the 
splint  fitted  to  the  upper  teeth.  The  jaws  are  then  closed  ujjon  the  splint 
and  kept  in  that  position  by  a  liarton  bandage.  Lateral  motion  is  prevented 
by  the  depressions  into  which  the  teeth  tit.  Such  an  interdental  splint 
can  be  made  thick  enough  to  permit  openings  for  feeding  between  the 
upper  and  lower  surfaces  of  the  splint.  An  illustration  of  this  splint  is 
shown  above  under  Fractures  "of  the  Upper  Jaw.  Instead  of  using  the 
upper  jaw  for  immobilization  the  splints  may  be  fitted  to  the  lower  jaw 
alone  and  attached  by  rods  coming  out  of  the  corners  of  the  mouth  to  a 
splint  under  the  chin.  A  simple  splint  is  made  by  softening  a  gutta- 
percha strip  in  hot  water,  moulding  it  to  the  crowns  of  the  lower  teeth  so 
as  to  overlap  the  adjacent  gum  and  hardening  it  by  cold  water.  Such  a 
splint  may  be  fixed  in  position  by  wires  carried  by  means  of  needles 
through  the  muscles  and  skin  of  the  chin  and  twisted  under  the  chin 
over  small  rolls  of  ])laster  or  pieces  ot  cork.  In  subjects  who  have  lost 
all  or  nearly  all  their  teeth  interdental  splints  moulded  to  the  atrophied 
gums  present  about  the  only  efficient  means  of  maintaining  immobility. 
In  all  forms  of  splints  greater  inimobility  will  as  a  rule  be  obtained  by 
bandaging  the  jaws  together.  If  desirable,  gutta-])ercha  wedges  may  be 
placed  between  the  jaws  on  each  side  of  the  mouth  in  order  to  have  a 
space  in  the  middle  for  introduction  of  food.  A  crude  form  of  interdental 
splint  may  be  made  of  cork  cut  to  fit  the  teeth  of  the  two  jaws. 


Fracture  of  the  Hyoid  Bone. 

The  hyoid  bone  is  rarely  broken,  and  when  sudden  lesion  is  sustained 
the  bone  usually  gives  way  near  the  junction  of  the  great  horn  and  the 
body  of  the  bone.  Fracture  of  the  hyoid  bone  is  at  times  associated  with 
fracture  of  the  laryngeal  cartilages,  and  is  due  to  similar  causes,  namely, 
pressure  of  the  rope  in  hanging,  grasping  the  throat  by  the  fingers  as  in 
homicidal  assaults,  and  direct  blows  upon  the  bone.  The  symptoms  of 
hyoid  fracture  are  sharp  pain,  increased  by  pressure,  speaking,  or  swallow- 
ing ;  swelling,  displacement  and  motion  of  the  fragments,  and  crepitus. 
If  the  mucous  membrane  of  the  pharynx  has  been  perforated  blood  will 
appear  in  the  mouth.  Sometimes  the  surgeon's  finger  in  the  pharynx 
will  detect  the  disi)lacemeut  with  ease.  Coughing  with  paroxysms  of 
choking  or  asphyxia  may  follow  attempts  at  swallowing  food  or  protruding 
the  tongue.  The  treatment  consists  in  replacing  the  fragments,  keeping 
the  parts  (luiet  by  prohibiting  talking,  and  feeding  the  patient  on  liquids 
by  means  of  a  tube.     Bandaging  the  throat  is  of  no  service. 

Fracture  of  the  Cartilages  of  the  Larynx. 

Pathology. — These  injuries,  owing  to  the  exposed  position  of  the 
larynx,  are  more  frequent  than  fracture  of  the  hyoid  bone.  They  are  at 
the  same  time  more  dangerous,  because  the  intralaryngeal  swelling  is 
very  liable  to  cause  fatal  asphyxia.  Blows,  falls,  hanging,  and  homicidal 
throttling  are  the  causes  likely  to  produce  laryngeal  fracture.  The 
mucous  membrane  is  frequently  torn,  leading  to  extravasation  of  blood 
within  the  larynx  and  emphysema  of  the  cellular  tissue  of  the  throat  and 
neighboring  regions.     The  upper  horn  of  the  thyroid   cartilage  is  some- 


FRACTURES    OF    THE    STERNUil. 


371 


times  developed  as  a  sort  of  epiphysis.  Epiphyseal  separation  may  then 
occur. 

Symptoms. — The  symptoms  are  deformity,  motion,  and  crepitation, 
accompanied  by  convulsive  cough,  alteration  or  loss  of  voice,  dyspnoea, 
painful  deglutition,  and  in  many  instances  frothy,  bloody,  expectoration. 
The  emphysema  that  is  seen  in  many  cases  may  spread  over  a  large  por- 
tion of  the  neck,  face,  and  trunk. 

In  severe  fractures  death  is  common  from  suffocation  due  to  subcuta- 
neous hemorrhage,  to  free  bleeding  into  the  larynx,  or  to  inflammatory 
or  emphysematous  swelling.  The  fatal  issue  may  suddenly  occur  several 
days  after  the  receipt  of  injury. 

Repair  occurs  most  probably  by  osseo-cartilaginous  material. 

Treatment. — The  treatment  consists  in  remedies  to  allay  inflamma- 
tion, and  cautionary  tracheotomy,  lest  fatal  obstructive  swelling  occur 
unexpectedly  in  the  larynx.  The  opening  thus  made  may  be  of  value  in 
giving  the  surgeon  an  opportunity  to  replace  the  broken  fragments  by  the 
introduction  of  instruments  into  the  air-passages.  It  is  unwise  to  post- 
pone tracheotomy  until  dyspnoea  becomes  extreme,  since  asphyxia  may 
be  sudden.  The  operation  had  better  be  done  in  all  cases  of  severe  frac- 
ture before  the  patient  is  left  by  the  surgeon.  A  permanent  tracheal 
opening  is  sometimes  demanded  after  fracture  of  the  laiynx. 

The  tracheal  rings  occasionally  sustain  fracture.  The  diagnosis  is  often 
difficult,  but  if  such  injury  is  discovered  it  should  be  treated  as  fracture 
of  the  larynx  by  antiphlogistic  measures  and  tracheotomy  below  the  seat 
of  injury. 

Fractures  of  the  Sternum. 


Pathology. — This  is  a  rare  injury,  probably  because  the  sternum  is 
protected  from  indirect  violence  by  being  connected  with  the  elastic 
costal  cartilages  and  ribs.  When  fracture  occurs  it  is  usually  due  to 
such  great  violence  that  associated  injury  to  the  ribs  or  thoracic  viscera 
exists ;  but  a  direct  blow  of  moderate  force  may,  if  limited  to  a  small 
area,  break  the  sternum.  Violence  which  forcibly  bends  the  spinal 
column  backward  or  forward  may  give  rise  to 
sternal  fracture  in  some  cases,  as  it  may  cause  ver-  Tig.  167 

tebral  fracture  in  others.  Great  muscular  efforts, 
such  as  occur  in  lifting  heavy  weights  or  in  par- 
turition, have  been  followed  by  disruption  of  this 
bone. 

The  first  portion  of  the  sternum,  or  manubrium, 
and  the  last  portion,  or  ensiform  appendix,  often 
become  united  in  adult  life  to  the  gladiolus,  or  cen- 
tral segment,  by  osseous  material.  In  early  life,  and 
sometimes  until  much  later,  more  or  less  perfect  joints 
exist  at  these  points.  Therefore  it  is  difficult  and 
often  impossible  to  say  whether  a  given  traumatic 
displacement  is  a  fracture  or  a  dislocation.  Dis- 
placement between  the  first  and  second  segments,  the 
result  of  direct  violence,  may  be  diagnosticated  as 
diastasis  or  dislocation  rather  than  fracture  when  Fracture  of  sternum. 
the  patient  is  young.     The  symptoms  confirmatory 

of  this  diagnosis  are  the  half  facets  for  the  second  ribs  or  a  smooth  upper 
facet  being  felt  through  the  skin,  the  cartilages  of  the  second  rib  being 


372 


DISEASES    AND    INJURIES    OF    BONES. 


Fig.  ItiS. 


out  of  place  and  easily  reduced  to  position,  and  no  crepitus  being  dis- 
coverable. In  fracture  tlie  periosteum  on  the  back  of  the  bone  is  more 
likely  to  be  torn,  hence  inflammatory  involvement  of  the  mediastinal 
structures  becomes  more  possible.  For  this  reason 
the  differential  diagnosis  has  some  bearing  on  prog- 
nosis. 

Sternal  fractures  are  generally  moi'e  or  less  trans- 
verse. Congenital  fissure  may  be  mistaken  for  lon- 
gitudinal fracture,  which  is  a  very  rare  lesion.  The 
freijuent  irregularities  of  the  ensiform  appendix  must 
not  be  forgotten.  Union  usually  occurs  promptly, 
and  little  annoyance  arises  from  uncomplicated  frac- 
ture even  if  some  deformity  persists.  Cases  asso- 
ciated with  rupture  of  the  lungs  or  pericardium,  or 
with  profuse  bleeding  or  consecutive  suppuration  in 
the  mediastinum,  are  of  grave  prognosis. 

SYMrTOMS.  —  The  symptoms  of  fracture  of  the 
sternum  are  displacement,  mobility,  crepitus,  pain  on 
motion,  deep  breathing  or  coughing,  bloody  expec- 
toration, dyspnwa,  and  sometimes  a  stooping  position 
of  the  shoulders  because  of  the  shortening  of  the 
breast  bone.  Replacement  can  best  be  accomplished 
by  traction  and  pressure.  If  a  hard  pillow  is  placed 
under  the  patient's  back  and  his  trunk  bent  back- 
ward over  it,  the  fragments  can  often  be  easily 
pressed  into  position.  A  deep  inspiratory  effort  may 
assist  the  reduction.  Recurrence  of  the  deformity 
is  not  unusual.  It  has  been  proposed  to  screw  a 
gimlet  into  the  depressed  portion  of  the  bone,  and 
thus  pull  it  upward,  or  to  insert  an  elevator  or  hook 
under  it.  These  means  increase  the  severity  of  the 
injury,  but  are  justified  by  symptoms  arising  from 
pressure  on  the  heart  and  lungs.  Unfortunately  the  bone  is  rather 
too  cancellous  in  structure  to  give  a  good  firm  hold  for  such  instru- 
ments. Entering  the  mediastinal  space  or  puncturing  the  pericardium 
or  pleural  cavity  is  to  be  deprecated.  After  reduction,  if  there  is  a 
tendency  to  displacement  or  much  pain  present,  the  chest  should  be 
immobilized  by  a  broad  bandage  of  flannel  or  adhesive  plaster  firmly 
applied,  while  the  lungs  are  emptied  by  forced  expiration.  If  intra- 
thoracic symptoms  arise,  they  should  be  treated  on  general  principles. 
Pus  behind  the  sternum  should  be  promptly  evacuated  by  incision  along 
the  side  of  the  sternum  or  by  trephining  the  bone.  Stimson  has  sug- 
gested removing  a  disk  of  bone  without  disturbing  the  posterior  perios- 
teum, and  then  puncturing  this  with  the  aspirator  needle,  which  may  be 
passed  in  various  directions  until  the  suspected  pus  cavity  is  found  or  its 
existence  disproved.  Antiseptic  incision  of  the  posterior  layer  of  the 
periosteum  would  seem  to  be  better  surgery.  A  post-sternal  abscess  may 
simulate  aneurism  because  of  its  transmitting  the  cardiac  pulsation. 


Transverse  fracture 
of  body  of  sternum. 
(Stimso.n.) 


Fractures  of  the  Bibs  and   Costal  Cartilages. 


Pathology. — Fractures  of  the  ribs  are  frequently  met  with  in  adults, 
but  quite  rarely  in  children.     The  greater  elasticity  of  the  bones  and 


FRACTURES    OF   THE    RIBS    AND  COSTAL    CARTILAGES.      373 

costal  cartilages  iu  childhood  sufficiently  accounts  for  this  difierence. 
The  occurrence  of  green-stick  fracture  may,  perhaps,  be  often  overlooked 
in  chest  injuries  among  children,  and  even  in  adults  the  periosteum  at 
times  remains  almost  intact,  and  thus  obscures  the  symptoms  of  fracture. 
The  protected  situation  of  the  first  and  second  ribs  behind  the  clavicle, 
and  the  mobility  of  the  last  two  ribs,  render  fracture  of  these  bones 
unusual.  The  ribs  most  commonly  broken  are  the  fourth,  fifth,  sixth, 
and  seventh.  Unless  several  ribs  are  simultaneously  broken  over-riding 
is  impossible,  for  the  adjoining  ribs  and  the  intercostal  structures  act  as 
splints.  Angular  deformity  is  in  the  same  way  a  good  deal  limited. 
Comminution,  when  great,  changes  the  rigid  thoracic  wall  into  a  flaccid 
membrane,  moving  in  and  out  with  respiration. 

Direct  violence,  by  driving  the  rib  inward,  causes  fracture  at  the  point 
of  impact,  and  generally  Avith  inward  displacement.  Indirect  violence, 
by  depressing  the  chest,  has  a  tendency  to  bend  the  rib  and  cause  frac- 
ture, beginning  on  the  external  surface.  Outward  displacement  is  prob- 
ably the  more  common  deformity  in  these  cases.  Erichsen  thinks  that 
in  indirect  fractures  the  bone  usually  gives  way  near  its  angle,  wdiich  is 
the  point  of  greatest  convexity.  Direct  injury,  of  course,  will  give  rise 
to  fracture  in  the  anterior  or  posterior  region,  according  as  the  violence 
is  received  upon  the  one  or  the  other  portion  of  the  bone.  Direct 
violence  is  more  apt  to  cause  splintering  of  the  inner  surface  of  the  bone 
and  inward  displacement ;  consequently  there  is,  under  such  causation, 
more  likelihood  of  puncture  of  the  viscera.  Contraction  of  the  extra- 
thoracic  muscles  during  violent  respiratory  efibrts,  as  in  coughing  or 
sneezing,  may  cause  fracture  of  a  rib.  The  rather  frequent  occurrence 
of  broken  ribs  iu  connection  with  general  paralysis  of  the  insane  is  said 
to  be  due  to  trophic  changes  in  the  bones  making  them  more  brittle. 

Injury  to  the  thoracic  or  abdominal  contents  is  not  an  infrequent  asso- 
ciate of  rib  fractures.  The  most  common  indication  of  such  injury  is 
subcutaneous  emphysema  about  the  seat  of  fracture  due  to  puncture  or 
rupture  of  the  pleura  and  lung.  This  is  probably  more  frequent  when 
the  rib  is  broken  at  the  situation  of  an  old  inflammatory  adhesion  of  the 
pulmonary  and  costal  pleura  than  when  no  such  adhesions  exist.  When 
the  wounded  lung  is  previously  non-adherent  the  air  from  the  bronchioles 
and  vesicles  sometimes  escapes  into  the  pleural  cavity,  giving  rise  to  pneu- 
mothorax instead  of  distending  the  subcutaneous  cellular  tissue  and  caus- 
ing emphysema.  The  lung  may  actually  become  compressed  and  collapsed 
by  large  quantities  of  air  and  blood  in  the  pleural  sac.  When  the  emphy- 
sematous condition  spreads  into  the  mediastinum  and  the  interlobular 
cellular  tissue  of  the  lung  the  patient's  condition  becomes  critical.  Peri- 
cardial and  heart  injuries  are  infrequent  except  after  very  great  violence. 
It  is  to  be  recollected  that  laceration  of  the  viscera  may  occur  without 
fracture  of  the  ribs. 

Laceration  of  an  intercostal  artery  may  happen  even  in  fracture  of  a 
not  very  serious  kind.  If  the  fracture  is  open  so  that  such  injury  and 
the  consequent  hemorrhage  are  detected,  efforts  should  be  made  to  secure 
the  bleeding  artery  by  passing  a  ligature  around  it.  This  can  perhaps  be 
done  by  a  curved  needle  carrying  a  thread  through  the  tissues  in  the 
intercostal  groove  on  the  lower  margin  of  the  rib,  or  by  drilling  the  bone 
and  passing  a  wire  through  it  and  around  the  vessel.  The  wound  may  be 
enlarged  so  that  a  small  key  can  be  passed  in  and  turned  in  such  a  manner 
as  to  press  on  the  vessel  for  a  few  hours.  In  some  cases  the  centre  of  a 
square  of  muslin  may  be  forced  into  the  thorax  so  as  to  make  a  pocket 


374  DISEASES    AND    INJURIES    OF    BOXES. 

within  the  wall.  Into  this  cotton  shoukl  be  pushed  so  as  to  make  the 
inner  part  of  the  packintr  Uirger  than  the  opening.  If  the  corners  of  the 
piece  of  muslin  are  then  pulled  forward  pressure  will  be  made  on  the 
intercostal  artery.  In  closed  fractures  an  incision  should  be  made  and 
similar  treatment  adopted  if  the  diagnosis  of  dangerous  hemorrhage  from 
a  torn  intercostal  artery  is  made. 

Symptoms. — The  symptoms  of  uncomplicated  fracture  of  the  ribs  may 
be  so  obscure  that  certainty  of  diagnosis  is  impossible.  Green-stick  frac- 
tures are  scarcely  recognizable  except  when  a  nodule  of  callus  is  devel- 
oped at  the  seat  of  pain  during  recovery.  Local  pain  induced  or  increased 
by  pi'essure,  motion,  full  inspiration,  or  coughing  is  suggestive  of  fracture, 
but  may  be  due  to  mere  contusion  of  the  soft  parts.  Shallow  or  catching 
respiration  is  a  common  acconipaniineut  of  broken  ribs  and  is  due  to  the 
pain  inflicted  by  deep  inspiratory  efforts.  Cough  is  often  present  and  has 
been  attributed  to  reflex  irritation  from  injury  to  the  intercostal  nerve 
lying  in  the  groove  of  the  bone. 

Pain  or  ecchymosis  at  a  distance  from  the  part  of  the  chest  upon  which 
the  violence  was  received  is  indicative  of  fracture.  I  have  learned  from 
Dr.  R.  J.  Levis  a  manipulation  that  has  often  convinced  me  of  the  exist- 
ence of  fracture  in  obscure  cases.  If  the  patient  lie  upon  his  back  and 
the  surgeon  make  strong  pressure  upon  the  sternum  and  anterior  part  of 
the  chest,  pain  will  often  be  experienced  at  the  point  of  fracture.  This 
is  due  to  the  elasticity  of  the  ribs  and  cartilages  causing  motion  at  the 
seat  of  fracture  even  when  it  exists  at  the  lateral  or  dorsal  aspect  of  the 
chest.  If  no  fracture  is  present  sternal  i)ressure  cannot  give  rise  to  pain 
at  a  distant  part  of  the  chest  wall.  Preternatural  motion  may  be  difficult 
to  obtain  and  recognize,  because  of  the  normal  mobility  and  elasticity  of  the 
thoracic  parietes.  Crepitation  may  be  elicited  by  applying  the  finger-tips 
to  the  ribs  on  both  sides  of  the  suspected  fracture  and  making  alternating 
pressure.  ^lotion  also  may  bo  thus  detected.  Sometimes  crepitation  is 
more  readily  detected  by  laying  the  palm  over  the  painful  spot  while  the 
patient  coughs  or  the  surgeon  makes  firm  pressure  in  the  neighborhood 
of  the  injury  with  the  other  hand.  Auscultation  may  detect  crepitus 
when  other  means  fail.  Subcutaneous  emphysema,  which  is  shown  by 
crackling  when  pressure  is  made  upon  the  skin  is  an  unmistakable  sign 
of  fractured  rib  and  puncture  of  the  lung.  The  development  of  a  pleur- 
itic friction  sound  or  of  a  local  pneumonia  a  day  or  two  after  injury,  is 
very  fair  evidence  of  a  broken  rib.  Bloody  expectoration,  pneumothorax, 
and  serous  effusion  or  hemorrhage  into  the  plural  sac  are  suggestive  of 
fracture  and  simultaneous  injury  of  the  thoracic  contents,  but  they  may 
also  occur  from  violence  that  does  not  break  the  elastic  ribs. 

The  prognosis  is  good  in  ordinary  uncomplicated  fractures  of  the  ribs. 
Union  occurs  in  about  four  weeks  by  interosseous  and  insheathing  callus 
which  often  leaves  an  irregularity,  even  when  no  displacement  existed, 
because  perfect  immobilization  is  impossible.  Sometimes  when  several 
bones  have  been  broken  bridges  of  callus  unite  the  upper  and  lower 
borders.  Hernia  of  the  lung  may  occur  if  much  displacement  or  commin- 
ution exists  after  severe  fractures.  The  cellular  emphysema  in  the  great 
majority  of  cases  is  unimportant  and  soon  disappears  spontaneously. 
Great  dyspncea  from  sudden  congestion  of  the  lungs  or  pneumothorax  is 
an  important  and  at  times  a  fatal  symptom.  Pleurisy,  pneumonia,  and 
pericarditis  occurring  as  complications  add  greatly  to  the  seriousness  of 
the  injury  and  should  always  be  looked  for  by  percussion  and  auscultation. 


FRACTUEES    OF    THE    RIBS    AND    COSTAL    CARTILAGES.      375 

Recovery,  however,  is  not  uncommon  after  severe  injury  to  the  lungs  and 
other  viscera. 

Treatment. — Fractures  of  the  ribs  should  be  treated  by  reduction  of 
displacement  and  immobilization.  At  the  same  time  the  surgeon  should 
be  on  the  alert  to  avert  or  relieve  intra-thoracic  inflammation.     Doubtful 

Fig.  169. 


United  rib  three  months  after  fracture.  (Holmes.) 
Fig.  170. 


Bridge  of  callus  between  broken  ribs.  (Holhes.) 

cases  are  to  be  treated  as  fractures.  Pressure  upon  the  ends  of  the  frag- 
ments or  upon  the  sternum  may  correct  deformity  and  at  the  same  time 
relieve  the  existing  pain.  Deep  inspiration  on  the  part  of  the  patient 
may  be  of  assistance.  Occasionally,  when  overlapping  exists  the  outer 
fragment  may,  by  pressure,  be  sprung  under  the  inner  one,  and  its  resili- 
ency used  to  lift  the  latter  outward  into  proper  relation.  If  inward  dis- 
placement were  causing  important  symptoms  it  would  be  proper  to  intro- 
duce a  hook  or  elevator  under  the  depressed  bone  and  thus  bring  it  into 
position.  In  gunshot  or  other  open  fractures  comminuted  and  detached 
pieces  may  at  times  be  extracted  with  propriety. 

Immobilization  is  to  be  effected  by  encircling  the  chest  with  a  broad 
bandage  so  that  thoracic  breathing  is  restricted.  The  ribs  are  thus  kept 
quiet  and  the  patient  required  to  breathe  by  the  diaphraghm  and  abdom- 
inal muscles.  The  bandage  should  be  made  of  a  piece  of  flannel  or  muslin 
about  eight  inches  wide  and  a  yard  and  a  half  long,  it  should  be  applied  and 
firmly  fastened  with  pins  during  full  expiration  in  order  to  be  sufiiciently 
tight.     If  the  patient  is  ordered  to  raise  his  arms  over  his  head  and  to 


376 


DISEASES    AND    INJURIES    OF    BONES. 


breathe  out  as  imicli  a.<  possible,  the  girth-like  bandage  can  be  firmly 
adjusted.  The  gypsum  dressing  may  be  tlnis  employed.  If  the  patient 
has  pain  from  the  circular  constriction  it  may  l)e  made  looser  or  entirely 
dispensed  with,  since  in  order  to  avert  pain  the  muscles  will  immobilize 
the  parts  pretty  well  without  external  assistance. 

The  bandage  must  never  be  carried  much  below  the  ensiform  cartilage, 
lest  it  interfere  Avith  the  play  of  the  abdominal  respiratory  muscles.  It 
may  be  prevented  from  slipping  downward  by  bands  carried  over  the 
shoulder.  The  arm  of  the  adducted  side  should  be  bound  to  the  chest 
or  carried  in  a  sling  if  the  motion  of  the  pectoral  muscles  gives  pain.  If, 
in  comminuted  fractures,  displacement  inward  is  caused  by  the  bandage 
it  must  be  removed.  A  laced  jacket  of  stout  linen,  such  as  has  been  used 
in  the  Pennsylvania  Hospital,  is  an  efficient  dressing  for  broken  ribs. 
The  dressing  may  be  discarded  in  about  four  weeks.  A  broad  sheet  of 
rubber  adhesive  plaster  or  several  overlapi)ing  strips  of  plaster  may  be 
used  instead  of  the  bandage.  Before  applying  adhesive  plaster  all  hair 
on  the  chest  should  be  removed  with  the  razor.  In  some  cases  constriction 
of  the  entire  chest  is  very  uncomfortable ;  this  is  especially  so  when  the 
patient  has  asthma  or  chronic  bronchitis.  The  adhesive  plaster  is  then  a 
preferable  dressing,  for  it  is  easy  to  apply  it  to  the  injured  side  only,  with 
the  ends  merely  crossing  the  median  line  in  front  and  behind. 


Fig.  171. 


Fio.  172. 


Bandage  for  fracture  of  ribs. 


Morton's  jacket  for  fracture  of  the  ri) 


The  intra-thoracic  inflaranuitions  require  treatment  similar  to  that 
indicated  in  similar  lesions  from  non-traumatic  causes.  The  cellular  em- 
physema accompanying  many  fractures  needs  no  special  treatment,  as  the 
air  is  soon  absorbed.  The  pressure  of  the  bandage  perhaps  aids  in  its 
disappearance.  Even  when  great  extension  of  the  emphysema  occure  no 
danger  is  to  be  apprehended  except  when  it  gets  into  the  mediastinum 
and  interlobular  tissue  of  the  lungs.  In  such  an  event  incisions  in  the 
skin  or  other  operative  interference  could  scarcely  avail.  Extreme  con- 
gestion of  the  lungs,  giving  rise  to  grave  dyspnoea,  should  be  treated  by 
venesection.  Pneumothorax,  hemorrhage  into  the  plural  sac,  or  large 
pleuritic  effusion  may  demand  aspiration  or  incision. 


FRACTURES    OF    THE    PELVIC    BONES. 


377 


Fractures  of  the  Costal  Cartilages. 

These  injuries  are  said  to  happen  most  frequently  near  the  junction  of 
the  cartilage,  and  rib,  and  to  occur  in  the  seventh  and  eighth  cartilages 
oftener  than  elsewhere.  The  partially  ossified  cartilages  of  the  old  are 
more  susceptible  of  fracture  than  the  cartilages  of  youth.  Chondral 
fractures  are  usually  transverse  or  nearly  so,  and  are  seldom  complicated. 
Deformity  is  the  most  constant  diagnostic  symptom,  though  at  times  crep- 
itus and  mobility  may  be  distinguishable.  When  it  is  impossible  to  deter- 
mine ^Yhether  fracture  or  dislocation  of  the  cartilage  has  taken  place  the 
termination  of  the  rib  may  be  made  out  by  acupuncture,  for  the  needle 
will  enter  the  substance  of  the  cartilage.  "Union  is  accomplished  not  by 
cartilage,  but  by  osseous  or  fibro-osseous  tissue  in  much  the  same  manner 
as  in  fracture  of  the  ribs.  The  perichondrium  seems  to  furnish  the 
ensheathing  callus.     The  treatment  is  the  same  as  that  for  fractured  ribs. 


Fractures  of  the  Pelvic  Bones. 

Pathology. — Fractures  of  the  pelvis  are  rare,  and  require  for  their 
production  a  great  degree  of  violence,  except  in  instances  where  mere 
projecting  f)rocesses  are  split  or  torn  off.  Falling  embankments,  railroad 
accidents,  and  the  passage  of  loaded  vehicles  across  the  trimk  are  the  kind 
of  injuries  liable  to  produce  fractures  of  the  pelvis.  The  fracture  lines 
are  apt  to  be  multiple,  because  the  crushing  force  wdiich  breaks  the  pelvic 


Fig.  173. 


,,x}^j!fj'^^ 


Plan  of  develo25ment  of  innominate  bone  by  three  primary  and  five  secondary 
centres.  (Gray.) 

girdle  brings  strain  at  the  same  time  on  various  parts.  Separation  of  the 
pubic  and  sacro-iliac  synchondroses  or  joints  is  not  an  unusual  result  of 
traumatism,  and  in  young  persons  the  epiphyseal  lines  of  the  innominate 
bone  may  be  forced  asunder  by  violence  that  in  older  persons  would  cause 


3<8  DISEASES    AND    INJURIES    OF    BONES. 

fracture.  The  pubic,  iliac,  and  ischiatic  elements  unite  between  the  years 
of  fifteen  and  twenty  ;  the  secondary  centres  at  about  twenty-five  years. 

The  usual  severity  of  the  causative  violence  and  the  relation  of  the 
pelvis  to  the  viscera  render  the  prognosis  as  to  life  unfavorable.  Lacera- 
tion of  the  urethra,  usually  in  its  membranous  portion,  rupture  of  the 
bladder,  rectum,  colon,  or  small  intestines  ;  injury  to  the  uterus  ;  rupture 
of  the  iliac  artery  or  vein  ;  and  contusion  or  laceration  of  the  solid  viscera 
are  not  at  all  infrcfpient  complications.  Death  from  secondary  affections, 
such  as  suppuration  in  the  cellular  tissue  of  the  pelvis  or  necrosis,  must  be 
recollected  as  a  possibility.  If  no  such  complications  occur,  cure  of  even 
severe  fractures  takes  place.  Union  may  be  expected  in  from  six  to  eight 
weeks,  but  lameness  is  usual  from  more  or  less  permanent  disability  of  the 
muscles  injured  by  the  accident,  or  restricted  in  their  function  by  the 
process  of  union  or  cicatrization.  Deformities  narrowing  the  pelvic  canal 
may  occasion  .serious  difficulty  in  subsequent  parturition. 

The  character  of  fracture  varies  with  the  direction  of  application  of  the 
fracturing  force.  Sometimes  the  fracture  lines  are  vertical,  one  or  more 
passing  through  the  rami  of  the  pubes  and  ischium  on  one  or  both  sides 
of  the  middle  line  and  another  through  the  iliac  portion  of  the  innominate 
bone  into  the  sacro-sciatic  notch.  In  the  po.sterior  segment  of  the  circle 
the  sacrum  may  be  s])lit  vertically,  or  the  sacro-iliac  joint  torn  open. 
Lateral  crushing  may  drive  the  head  of  the  femur  through  the  acetabulum 
into  the  pelvic  cavity  ;  or,  if  less  severe,  may  produce  lines  of  fracture 
radiating  from  the  acetabular  region.  Parturition,  forced  abduction  of 
the  thighs,  and  direct  external  violence  have  produced  separation  of  the 
symphysis  of  the  pubes.     The  separation  is  said  to  occur  between  one  of 


Fio.  174. 


Fig.  i: 


Fracture  through  ramus  of  pubes  and  saero-iliac 
junction. 


Fracture  of  pelvis  with  head  of 
femur  forced  through  acetabulum. 
Autopsy  several  years  after  in- 
jury.   (Bryant.) 


the  pubic  bones  and  its  attached  cartilage  rather  than  between  the  two 
cartilages  which  the  joint  contains.  The  gap  felt  through  the  integument 
may  be  as  much  as  two  inches  wide.  Occasionally  the  symphysis  of  the 
pubes  and  one  of  the  sacro-iliac  articulations  have  been  torn  open  so  that 
half  of  the  pelvis  and  the  corresponding  leg  have  been  markedly  displaced 
upward. 

Of  the  fractures  which  involve  the  continuity  of  the  pelvic  ring,  that 
in  the  pubic  region  is  mo.st  common,  for  here  the  bony  constituents  of  the 
pelvis  are  most  fragile. 


FRACTURES    OF    THE    PELVIC    BONES.  379 

Transverse  or  nearly  transverse  fractures  of  the  sacrum  or  of  the  coccyx 
are  occasional  lesions.  In  both  the  tendency  is  for  the  lower  fragment  to 
be  bent  inward  with  its  lower  extremity  pointing  toward  the  interior  of 
the  pelvis.  Dislocation  of  the  coccygeal  articulations  is  practically 
identical  with  fracture  of  the  ankylosed  bone. 

Symptoms. — Displacement  is  not  very  great  in  the  majority  of  pelvic 
fractures ;  but  palpation  will,  if  the  parts  are  accessible,  usually  show 
either  deformity,  mobility,  or  crepitus.  Vaginal  and  rectal  exploration 
will  be  servicable  in  a  few  cases.  Shortening  of  the  lower  extremity  from 
upward  displacement  of  the  pelvis,  and  inability  or  indisposition  to  move 
the  limb  will  at  times  aid  in  the  diagnosis.  Loss  of  support,  fear  of  pain, 
and  laceration  of  the  muscles  attached  to  the  pelvis  may  all  have  part  in 
the  production  of  this  disability.  A  good  deal  of  subcutaneous  exti*ava- 
sation  of  blood  is  frequently  a  feature  of  these  injuries. 

Careful  observation  of  the  relative  position  of  the  anterior  spinous 
processes  of  the  ilium  will  at  times  serve  to  strengthen  or  weaken  an 
obscure  diagnosis.  Crepitus  may  be  elicited  and  correction  of  deformity 
secured  by  traction  on  the  lower  limb.  Escape  of  blood  from  the  urinary 
meatus  or  rectum,  retention  of  urine,  bloody  urine,  and  the  rapid  super- 
vention of  tympanites  or  peritonitis  suggest  the  probability  of  fracture  of 
the  pelvis  in  cases  with  appropriate  history. 

In  sacral  fracture,  paralysis  of  rectum,  bladder,  and  legs,  from  compli- 
cating lesion  of  the  sacral  nerves,  is  said  to  be  not  unusual ;  and  pain  on 
coughing  or  defecation  may  be  expected.  Seizing  the  bone  between  a 
finger  in  the  rectum  and  the  thumb  on  the  dorsum  will  probably  demon- 
strate motion  and  crepitus,  and  perhaps  correct  displacement. 

Coccygeal  fracture  occurs  probably  more  frequently  from  parturient 
efforts  and  manipulations  than  from  other  traumatism.  Rectal  examina- 
tion will  often  establish  the  correct  diagnosis  and  reduce  the  displaced 
fragments. 

Fractures  of  the  crest  or  processes  of  the  ilium  are  probably  the  least 
important  of  the  fractures  of  the  pelvic  bones,  for  they  have  as  a  rule  no 
serious  complications,  and  confine  the  patient  to  bed  for  only  a  couple  of 
weeks  or  perhaps  not  at  all. 

Mere  fissure  of  the  cavity  of  the  acetabulum  has  no  characteristic 
symptom. 

Fracture  of  the  rim  of  the  acetabulum  is  worthy  of  consideration.  It 
usually  occurs  as  the  result  of  great  violence  applied  to  the  hip,  and  as  an 
accompaniment  of  dislocation  of  the  femur.  Dislocation  backward  of 
the  head,  with  breaking  of  the  posterior  and  upper  margin  of  the  ace- 
tabular rim,  is  the  ordinary  form  of  the  lesion.  The  symptoms  are  those 
of  dislocation  of  the  head  of  the  thigh-bone  with  crepitus,  and  a  ready 
recurrence  of  the  dislocation  after  its  reduction.  Fracture  of  the  neck 
of  the  femur  may  be  mistaken  for  dislocation  and  fracture  of  the 
acetabular  margin,  because  crepitus  and  recurrence  of  deformity  are 
essentially  marked  symptoms  in  the  former  injury.  In  fracture,  however, 
unless  it  is  impacted,  the  limb  assumes  a  position  of  outward  rotation  and 
extension,  while  in  the  posterior  dislocations,  which  are  the  varieties 
likely  to  be  seen  here,  the  limb  takes  the  position  of  inward  rotation  and 
flexion  on  the  pelvis.  Again,  in  fracture  the  trochanter  is  relatively 
nearer  the  anterior  superior  spine  of  the  ilium  than  in  dislocation.  It 
is  well  in  all  cases  of  doubt  to  make  sure  of  the  actual  position  of  the 
head,  and  also  to  remember  that  dislocation  of  the  femoral  head  compli- 
cated with  fracture  of  the  neck  of  the  bone  is  not  impossible,  and  that 


380  DISEASES    AND    INJURIES    OF    BONES. 

the  crepitus  attributed  to  fracture  of  the  acetabulum  may  exist  really 
between  the  fragments  of  the  broken  femoral  neck. 

Tkkatmext. — The  treatment  of  fractures  of  the  pelvic  bones  varies 
with  the  location  of  the  injury  ;  but  in  all  the  severer  forms  of  fracture 
the  surgeon  should  at  once  introduce  a  catheter,  in  order  that  laceration 
of  the  urethra  may  be  discovered,  if  it  exist,  before  extensive  extravasa- 
tion of  urine  has  occurred.  Shock  must  also  be  treated.  If  the  end  of 
the  catheter  will  not  i>ass  beyond  the  torn  portion  of  the  urethra  into  the 
bladder,  a  perineal  incision  should  immediately  be  made.  This  incision 
should  be  made  in  the  middle  line  and  should  open  the  tissues  down  to 
the  seat  of  rupture,  to  which  the  end  of  the  catheter  left  in  i)lace  is  a 
guide.  Exit  is  thus  given  for  the  urine  to  pass  from  the  opening  in  the 
urethra  to  the  exterior,  and  disastrous  extravasation  into  the  perineal 
structures  is  averted.  It  is  not  proper  to  open  the  neck  of  the  bladder 
unless  the  bladder  itself  is  ru])tured.  The  incision  down  to  and  into  the 
urethra  at  the  point  of  its  rupture  is  all  that  is  required  to  conduct  the 
urine  to  the  surface.  The  case  should  then  be  managed,  so  far  as  this 
feature  is  concerned,  as  one  of  external  urethrotomy  for  stricture,  by  the 
occasional  passage  of  a  bougie.  If  a  catheter  can  be  introduced  through 
the  torn  urethra  into  the  bladder  no  incision  is  demanded,  and  the  instru- 
ment, preferably  a  rubber  one,  should  be  retained  in  the  bladder  for  a 
few  days  until  danger  of  urinary  infiltration  has  passed. 

Violent  manipulation  may  increase  visceral  damage  in  pelvic  fractures 
and  should  be  avoided,  though  careful  efforts  at  correcting  marked  dis- 
placements are  proper.  Rest  in  bed  in  the  dorsal,  prone,  or  lateral  posi- 
tion, according  to  the  comfort  of  the  patient,  and  support  to  the  pelvis 
by  encircling  bands  of  adhesive  plaster  or  by  a  broad  girdle  of  muslin  or 
flannel  will  usually  meet  the  indications.  All  pressure  liable  to  cause 
displacement  or  pain  must  be  avoided  by  pads.  A  gypsum  dressing  may 
sometimes  be  serviceable.  Continuous  traction  by  weights  attached  to 
the  leg  and  thigh  as  in  fracture  of  the  femur,  may  be  the  only  means  of 
preventing  upward  displacement  in  double  vertical  fractures  on  the  same 
side  of  the  median  line.  Fractures  of  the  ischium  may  rerjuire  pressure 
to  be  applied  within  the  rectum  in  order  to  effect  coaptation  of  fragments. 
The  finger  or  a  woriden  lever  may  be  employed.  A  few  cases  have  been 
treated  efficiently  by  means  of  packing  kept  in  the  rectum  for  a  series  of 
days  to  prevent  recurrence  of  displacement.  The  packing,  which  should 
be  enclosed  in  a  rubber  bag,  must  be  occasionally  removed  to  allow  defe- 
cation and  escape  of  flatus,  unless  a  canula  be  placed  through  the  centre 
of  the  distending  apparatus.  A  rubber  bag  distended  with  air  or  water 
and  well  oiled,  when  inserted,  would  seem  to  be  the  most  judicious  means 
for  effecting  this  seldom  required  intra-rectal  pressure.  In  fractures  of 
the  iliac  Avings  the  encircling  bandage  must  be  omitted  if  it  tends  to  ])ress 
the  fragments  abnormally  inward.  In  fracture  of  the  tuberosity  of  the 
ischium  the  hamstring  muscles  should  be  relaxed  by  flexing  the  leg  on 
the  thigh,  while  the  thigh  should  be  extended  or  semi-extended  at  the 
hip.  In  instances  of  great  comminution,  followed  by  extensive  suppura- 
tion, provision  for  free  drainage  should  be  made,  and  detached  .splinters 
of  bone  removed  early. 

The  neuralgic  affection,  coccygodynia,  whose  symptoms  are  not  unlike 
fissure  of  the  anus,  may  be  a  secondary  result  of  fracture  of  the  coccyx. 
If  subcutaneous  division  of  the  soft  structure  attached  to  the  coccyx  fails 
to  relieve  the  pain,  removal  of  the  bone  by  means  of  the  cutting  forceps 
or  saw,  or  with  the  burr  of  the  surgical  engine,  may  be  performed. 


FRACTURE    OF    THE    CLAVICLE. 


381 


Fracture  of  the  Clavicle. 

Pathology. — Direct  violence  and  muscular  strain,  as  in  lifting  heavy- 
weights, may  cause  fracture  of  the  clavicle.  By  far  the  most  common 
cause,  however,  is  indirect  violence,  for  in  falls  upon  the  shoulder,  elbow, 
or  hand  the  force  of  impact  is  transmitted  to  the  clavicle,  which  consti- 
tutes the  only  bony  connection  of  the  arm  with  the  trunk.  A  tendency 
to  exaggerate  the  curves  of  this  doubly  curved  and  doubly  twisted  bone 
is  thus  produced  and  the  bone  gives  way  as  soon  as  the  strain  becomes  too 
great.  The  mechanism  of  some  cases  of  fracture  is,  it  is  said,  a  forcible 
bending  of  the  clavicle  across  the  first  rib,  with  which  it  normally  is 
often  almost  in  contact.  With  the  exception  of  the  radius  the  clavicle  is 
the  most  frequently  broken  bone  of  the 'skeleton. 

The  outer  part  of  the  middle  third  is  the  most  common  site  of  fracture, 
but  from  its  obliquity  the  line  may  extend  into  the  outer  or  inner  third. 
The  small  diameter  of  the  bone  and  the  sharj^ness  of  the  curve  at  this 
point,  associated  with  the  frequent  causation  from  indirect  violence,  are 
satisfactory  reasons  for  the  lesion  showing  this  preference. 

Comminuted,  multiple,  or  open  fractures  of  the  clavicle  are  rare. 
Green -stick  fractures  are  common ;  and  transverse  breaks  with  little  dis- 
placement or  laceration  of  periosteum  by  no  means  unusual.  Emphysema 
from  puncture  of  the  apex  of  the  lung,  paralysis  from  laceration  or  con- 
tusion of  the  nerve  trunks,  and  lesions  of  the  subclavian  vessels  are  pos- 
sible but  almost  unknown  complications. 


Fig.  17fi. 


Fig.  177. 


Deformity  from  fracture  of  clavicle  united  with  displace- 
ment.    (Hamilton.) 


Fracture  of  clavicle. 


Symptoms. — The  usual  deformity  after  the  ordinary  fracture  of  the 
middle  portion  of  the  clavicle  is  produced  by  tilting  upward  of  the  outer 
end  of  the  sternal  fragment,  and  displacement  inward,  forward,  and  down- 
ward of  the  inner  end  of  the  acromial  fragment.  The  projection  upward 
of  the  former  has  been  attributed  to  the  lifting  force  exerted  by  the  outer 
fragment  being  thrust  under  it,  and  also  to  contraction  of  the  sterno- 
cleido-mastoid  muscle.     The  displacement  inward,  forward,  and  downward 


382 


DISEASES    AND    INJURIES    OF    BOXES, 


Fig.  178. 

VERTE3RA 


STERNUM 


Diagram  showing  sliding  forward 
of  scapula  and  tilting  out  of  its  pos- 
terior border  in  fracture  of  clavicle. 


of  the  acromial  fragment  i.s  due  to  the  fact  that  the  clavicle  is  the  support 
or  stay  which  holds  the  .^capula  and  its  attached  arm  in  proper  relation 
to  the  thorax.  When  the  clavicle  is  broken,  the  scapula,  partly  by  reason 
of  the  weight  of  the  arm  and  [)artly  by  the  action  of  the  great  serrated 
and  the  lesser  pectoral  muscles,  assisted,  perhaps  by  the  rhomboids,  is  ro- 
tated forward  around  the  dorso-lateral  aspect  of  the  chest  in  such  a  way 
as  to  depress  the  acromion  and  carry  it  toward  the  anterior  middle  line 
of  the  trunk.  This  displacement  of  the  point  of  the  shoulder  and  the 
consequent  relation  of  the  clavicular  fragments  are  well  shown  in  the 
diagram  adapted  from  Stimson.     It  represents  in  a  schematic  way  the 

intact  as  well  as  the  broken  shoulder- 
girdle  as  the  claviculo-scapular  combina- 
tion has  been  called.  The  inward  and 
forward  displacement  of  the  acromion  is 
seen  at  a  glance.  The  downward  deform- 
ity, being  in  another  plane,  is  of  course 
not  exhibited.  Shortening  of  the  clavicle 
is  great  in  oblique  fractures  with  over- 
riding, and  may  amount  to  one  and  a  half 
or  two  inches.  Sometimes,  in  transverse 
fractures,  interlocking  of  fragments  gives 
upward  and  backward  angular  deformity. 
In  all  fractures  the  continuance  of  the 
fracturing  force  after  rupture  of  bone 
has  occurred,  and  the  line  of  break  have 
influence  in  determining  the  amount  and 
direction  of  the  displacement. 
Fractures  of  the  outer  third  of  the  clavicle  are  often  transverse,  and,  in 
reference  to  fre(iuency,  come  next  to  fractures  of  the  middle  third.  The 
displacement  is  believed  by  some  writers  to  be  greater  as  the  line  of  sepa- 
ration approaches  the  acromion  and  gets  outside  of  the  attachment  of  the 
coraco-clavicular  ligament.  This,  however,  is  denied  by  the  high  au- 
thority of  Gurlt  and  Gordon.  The  deformity  is  usually  angular,  with 
the  acromial  fragment  thrown  forward. 

In  fractures  of  the  inner  third  the  most  usual  deformity  is  due  to  dis- 
placement downward  and  forward  of  the  inner  end  of  the  acromial  por- 
tion of  the  bone,  or  angular  distortion  of  both  fragments  in  the  same 
direction. 

The  local  deformity  arising  in  fractured  clavicle  has  been  discu.ssed  ; 
but  in  addition  there  is  foiling  inward  and  forward  of  the  shoulder,  and 
projection  of  the  inferior  angle  and  posterior  border  of  the  scapula. 
This  is  an  especially  prominent  feature  of  the  injury  when  great  over- 
lapping occurs  in  lesions  in  the  middle  third  of  the  bone.  On  account  of 
the  usually  indirect  causation  of  the  injury,  contusion,  if  existent,  will  be 
found  on  the  shoulder,  elbow,  or  hand,  and  not  at  the  seat  of  fracture. 
Crepitus  may  not  be  perceptible  until  the  shoulder  is  pressed  outward  and 
backward,  so  as  to  bring  the  ends  of  the  overlapping  fragments  together. 
A  loss  of  function,  due  to  pain  induced  by  movements,  and  not  to 
mechanical  obstruction,  is  shown  in  inability  to  place  the  hand  on  the 
head  while  the  latter  is  held  erect,  or  to  raise  the  arm  so  as  to  hold  it  out 
at  a  right  angle  with  the  trunk.  In  green-stick  fractures  fixed  local  pain 
may  be  the  single  symptom,  until,  in  the  course  of  a  fortnight,  a  small 
nodule  of  callus  is  perceptible.  This  condition  must  be  discriminated 
from  the  localized  pain  and  subsequent  nodular  deformity  of  syphilitic 


FRACTUKE    OF    THE    CLAVICLE,  383 

periostitis.  Fractures  near  the  acromial  end  of  the  clavicle  simulate 
dislocation. 

The  vascularity  of  the  collar  bone  enables  union  to  become  quite  firm 
by  the  end  of  the  third  week.  Non-union  is  rare,  and,  when  occurring, 
produces  a  very  moderate  degree  of  disability.  Impairment  of  function 
from  pressure  of  exuberant  callus  on  the  vessels  and  nerves  behind  the 
clavicle  is  a  remote  possibility.  The  paralysis  sometimes  attributed  to 
such  cause  is  oftener,  perhaps,  the  result  of  injurious  pressure  of  a  large 
axillary  pad  used  in  treating  the  fracture. 

Treatment. — Cure,  without  deformity,  of  clavicular  fractures  present- 
ing much  primary  displacement,  seems,  with  our  present  appliances,  to  be 
almost  impossible.  Fortunately  the  permanent  distortion  so  often  left  is 
a  cosmetic  defect  rather  than  a  disability. 

The  probability  of  permanent  deformity  after  complete  fracture  renders 
it  wise  to  desist  from  too  active  attempts  to  straighten  the  bone  of  the 
green-stick  fracture,  for  if  complete  separation  is  caused  by  the  manipula- 
tion greater  disfigurement  is  liable  to  occur.  Straightening  should,  there- 
fore, be  attempted  only  with  a  moderate  degree  of  force,  especially  as  the 
bent  bone  may  even  regain  something  of  its  normal  shape  during  the 
after-growth  of  the  patient. 

In  complete  fractures  correction  of  deformity  is  to  be  attempted  by 
grasping  the  scajnda  and  swinging  it  around  the  posterior  chest  Avail 
toward  the  median  line  of  the  back,  and  holding  its  lower  angle  against 
the  ribs.  This  procedui'e  tends  to  carry  the  acromion  and  head  of  the 
humerus  outward  and  backward,  and  thus  to  restore  the  position  of  the 
shoulder,  which  has  been  changed  by  the  loss  of  the  support  given  by  the 
unbroken  clavicle.  At  the  same  time  moulding  of  the  fragments  at  the 
seat  of  fracture  should  be  practised.  A  similar  effect  may  sometimes  be 
produced  by  standing  behind  the  patient  and  pulling  the  shoulder  back- 
ward with  one  hand,  while  coaptation  is  secured  by  pressure  with  the 
other  hand  at  the  seat  of  lesion.  Good  position  is  usually  obtainable  by 
these  manoeuvres.  The  difiiculty  in  treatment  arises  from  the  impossi- 
bility of  retaining  correct  apposition  for  three  or  four  weeks  by  apparatus 
that  can  be  tolerated  by  the  patient  and  worn  during  walking. 

Dorsal  recumbency  on  a  firm,  level  mattress,  with  the  head  bent  a  little 
forward  by  a  small  pillow  and  the  injured  arm  laid  and  fixed  by  a  ban- 
dage or  adhesive  strip  across  the  chest  with  the  elbows  close  to  the  ribs,  is 
the  best  method  of  treatment.  In  this  posture  the  weight  of  the  body 
keeps  the  scapula  pressed  against  the  chest,  and  prevents  it  rotating  for- 
ward. A  bag  of  shot  or  sand  may,  if  necessary,  be  laid  upon  the  acromion 
to  hold  the  shoulder  more  firmly  outward  and  backward.  The  position 
of  the  arm  also  aids  in  maintaining  coaptation  and  preventing  over-riding. 
Few  persons,  excejDt  perhaps  women  who  occasionally  dress  so  as  to  ex- 
pose the  neck,  care  to  maintain  this  irksome  posture  for  several  weeks, 
especially  when  informed  of  the  fact  that  deformity,  though  unsightly,  is 
not  prejudicial  to  good  use  of  the  arm.  Experience,  however,  seems  to 
show  that  if  this  line  of  treatment  is  continued  for  ten  days  or  two  weeks 
the  solidification  of  the  fracture  becomes  such  that  the  erect  posture  may 
be  assumed,  in  conjunction  with  the  oi'dinary  fracture  dressing,  without  any 
great  tendency  to  reproduction  of  displacement.  The  best  treatment  for 
fractured  clavicle,  therefore,  is  the  recumbent  posture  for  about  ten  days, 
followed  by  the  ordinary  dressings,  when  the  patient  is  released  from  his 
confinement  in  bed,  for  about  three  weeks  more.  When  the  least  pos- 
sible deformity  is  especially  desirable,  the  recumbent  posture  should  be 


384 


DISEASES    AND    INJURIES    OF    BOXES. 


retained  for  three  or  four  weeks.  Continuous  coaptating  digital  pressure 
could  be  maintained  for  several  weeks,  if  necessary,  to  insure  more  abso- 
lute perfection  in  the  result.  The  free  administration  of  chloral  and 
bromide  of  potassium  will  overcome  the  nervous  restlessness  which  the 
requisite  immobility  of  the  trunk  engendex's. 

When  confinement  to  bed  is  objected  to  by  the  patient  the  dressing 
of  Bryant,  Sayre,  or  Velpeau  should  be  adopted.  Jiryant  reduces  the 
fracture  and  then  places  a  pad  over  the  scapula  below  its  spine  and  binds 
the  bone  firmly  to  the  chest  by  strips  of  adhesive  plaster,  extending 
from  the  vertebral  spines  to  the  sternum.  The  arm  of  the  injured  side  is 
then  supported  in  a  sling,  with  the  hand  drawn  upward  toward  the  op- 
posite shoulder.  Sayre  uses  two  strips  of  adhesive  plaster  about  three 
inches  wide  an  1  one  and  a  half  to  two  yards  long.  At  the  end  of  one 
strip  a  large  loop,  with  the  back  of  the  plaster  inward,  is  made  by  stitch- 
ing with  a  needle  and  thread.  After  the  skin  of  the  chest  has  been 
shaved,  the  injured  arm  is  passed  through  this  loop,  which  must  be  loose 
enough  not  to  constrict  the  vessels.  The  elbow  is  then  drawn  well  hack- 
ivard  and  fixed  in  that  position  by  the  free  end  of  the  plaster  being  carried 
around  the  entire  chest  from  back  to  front,  as  shown  in  the  illustration. 


Fig.  179. 


First  stage  of  Sayre's  dressing  for  fractured 
clavicle. 


Sayre's  dressing  for  fractured 
clavicle  completed. 


This  end  should  also  be  secured  by  stitching,  if  there  is  any  probability  of 
the  plaster  slipping.  The  flexed  forearm  is  now  laid  across  the  chest  and 
the  elbow  carried /orn'a?Y/,  so  that  the  loop  of  the  first  strip  is  made  to  act 
as  a  fulcrum.  The  middle  of  the  second  strip  is  then  applied  under  the 
olecranon  and  the  elbow  forced  upward  by  carrying  the  ends  of  the  plas- 
ter along  the  forearm  and  across  the  back  to  the  opposite  shoulder.  A 
slit  should  be  made  in  this  strip  at  the  elbow,  to  relieve  the  olecranon  of 
painful  pressure,  and  pieces  of  lint  should  be  placed  under  the  forearm  and 
in  the  axilla  to  prevent  irritation  from  sweating.  In  cool  weather  this 
dressing  may  require  no  renewal  during  the  time  necessary  to  maintain 
immobility.  If  the  fragments  project  upward  notwithstanding  the  dress- 
ing, a  compress  may  be  placed  upon  the  seat  of  fracture  and  held  there 
by  a  short  strip  carried  down  the  back  and  front  of  the  chest.  A  pad  of 
cloth,  covered  with  plaster  with  the  adhesive  side  outward,  will  stick  to 


FRACTURES  OF  THE  SCAPULA. 


385 


Fig.  181. 


the  skin  and  not  easily  slip  out  of  position.  The  hand  may  be  left  free,  if 
desired,  by  passing  the  second  strip  along  the  ulnar  side  of  the  wrist.  This 
lessens  the  discomfort  of  the  dressing. 

A  good  dressing  in  many  cases  is  that  of  Velpeau.  After  placing  the 
hand  of  the  injured  side  on  the  opposite  shoulder,  a  roller  bandage  is 
carried  from  the  scapula  of  the  well  side 
obliquely  over  the  back  to  the  injured  shoul- 
der, over  this,  down  the  outside  of  the  arm, 
under  the  elbow,  across  the  chest  to  the  ojDposite 
axilla  and  to  the  point  of  starting.  When  the 
arm  has  been  well  supported  by  several  turns 
of  this  kind,  the  bandage  is  carried  around  the 
thorax  and  arm  by  circular  turns  from  elbow 
upwai'd.  This  dressing  can  be  made  more  se- 
cure by  coating  it  with  silicate  of  sodium  or 
gypsum,  or  by  applying  several  narrow  strips 
of  adhesive  plaster,  about  a  foot  in  length,  ver- 
tically over  its  folds. 

A  number  of  dressings  for  broken  clavicle 
employ  an  axillary  pad,  with  the  idea  that  it 
acts  as  a  fulcrum  by  which  to  force  the  shoulder 
outward.  The  pad  is  probably  of  little  value 
unless  too  large  and  too  firm  to  be  worn  with 
comfort  and  with  safety  to  vessels  and  nerves  ; 
but  it  may,  perhaps,  be  serviceable  if  so  applied 
as  to  act  as  a  compress  upon  the  axillary  border  of  the  scapula  and  pre- 
vent sliding  forward  of  that  bone.  It  forms  no  part  of  any  of  the  dress- 
ings recommended  above. 

In  children  the  dressing  for  fractured  clavicle  should  be  continued  for 
two  or  three  weeks,  in  adults  three  or  four  weeks. 


Velpeau's  dressing    for 
ture  of  clavicle. 


Fractures  of  the  Scapula. 

The  mobility  of  the  scapula  and  its  environment  by  muscular  masses 
protect  it  quite  efficiently  from  fracture  under  ordinary  forms  of  acciden- 
tal injury.  Fracture,  when  it  does  occur,  is  usually  of  the  body,  acromion, 
or  surgical  neck.  The  spine  and  the  coracoid  process  also  suffer  fracture, 
but  these  lesions  are  of  great  rarity.  The  rim  of  the  glenoid  cavity  is  oc- 
casionally chipped  off  in  dislocations  of  the  head  of  the  humerus,  and  the 
cavity  itself  may  at  times  be  fissured,  but  the  obscurity  of  the  symptoms 
renders  diagnosis  almost  impossible. 

In  suspected  fracture  of  the  body,  placing  the  forearm  across  the  chest 
or  behind  the  back  will  render  the  posterior  border  of  the  bone  suffi- 
ciently prominent  to  enable  the  surgeon  to  detect  deformity  from  displace- 
ment. Crepitus  is  best  obtained,  perhaps,  by  placing  the  palm  of  one 
hand  over  the  scapula  while  the  patient's  arm  is  moved  in  various  direc- 
tions, or  by  the  examiner  insinuating  his  fingers  under  the  inferior  angle 
of  the  bone  and  endeavoring  to  obtain  motion  while  he  steadies  the  upper 
part  of  the  bone  with  the  other  hand  on  the  shoulder.  The  ridges  some- 
times so  well  marked  along  the  borders  and  spinous  process  of  the  bone, 
must  not  be  mistaken  for  fracture  with  displacement. 

Reduction  of  the  fragments  may  be  difficult  but  should  be  attempted 
by  pressure  while  the  patient's  arm  is  moved  in  various  directions.    Broad 

25 


386 


DISEASES    AND    INJURIES    OF    BONES. 


adhesive  strips  carried  across  the  scapula  ami  partly  around  the  thorax, 
and  a  bandage  applied  to  raise  the  elbow  and  keep  the  arm  against  the 
side  in  a  more  or  less  vertical  i)osition,  furnish  an  ai)propriate  dressing. 
Union  takes  place  in  about  four  weeks  and  good  use  of  the  limb  is  to  be 
expected,  even  if  some  deformity  persists.  In  open  fractures  suppuration 
niav  occur  from  bacterial  infection,  and  pus  burrow  under  the  scapula. 
This  should  be  averted  by  furnishing  facilities  for  drainage  as  soon  as 
needed. 

Fracture  of  the  acromion  and  separation  of  the  acromial  epiphysis  are 
lesions  often  indistinguishable.  The  two  centres  of  ossification  for  the 
acromion  appear  about  the  sixteenth  year,  and  ossification  is  complete 
between  the  twenty-second  and  twenty-fifth  year.  Hence,  direct  violence 
falling  upon  the  elbow  or  muscular  contraction  maj'  easily  cause  e])iphy- 
seal  separation  even  in  adults. 

The  line  in  acromial  fracture  is  usually  either  in  front  of  the  articula- 
tion with  the  clavicle  or  at  the  root  of  the  acromion  ])rocess.  Absence  of 
deformity  and  contusion  of  the  soft  parts  may  obscure  the  recognition  of 
the  lesion.  When  the  process  is  broken  at  its  base  much  fiattening  of  the 
shoulder  is  produced  by  the  weight  of  the  arm  pulling  the  fragment 
downward  and  inward.  Less  deformity  results  when  the  mere  tip  is 
broken  off.  Inability  to  abduct  the  arm  usually  accompanies  acromial 
fracture ;  and  crepitation  may  be  obtained  by  grasping  the  shoulder 
while  the  elbow  is  forcibly  pushed  upward.  Fibrous  is  more  common 
than  bony  union,  probably  because  close  contact  of  fragments  is  not 
obtained.  The  indication  for  treatment  is  to  immobilize  the  arm  with  the 
head  of  the  humerus  forced  well  up  again.st  the  scapula.  Velpeau's  dress- 
ing for  clavicular  fracture  answers  the  purpose  very  well,  and  should  be 
continued  about  four  weeks.  The  least  deformity  is  probably  obtained 
by  keeping  the  patient  on  his  back  in  bed  with  the  arm  extended  at  a 
right  angle  to  the  trunk,  in  order  to  relax  the  deltoid,  which  is  the  dis- 
placing muscle. 


Fig.  1S2. 


P^iG.  18.3. 


Fracture  of  surgical  neck  of  scapula  according       Spence's  case  of  fracture  of  the  neck 
to  Cooper.  of  the  scapula.     (Gi'ri-t.) 

Fracture  limited  strictly  to  the  constriction  immediately  behind  the 
glenoid  cavity,  which   has  been  called  the  anatomical  neck  of  the  bone, 


FEACTURES    OF    THE    HUMERUS. 


387 


is  practically  unknown.  Fracture  may  take  place,  however,  behind  the 
coracoid  process  in  a  line  passing  downward  from  the  supra-scapular 
notch,  or  in  such  a  direction  as  to  spKt  off  most  of  the  head  of  the  bone 
while  leaving  the  coracoid  process  attached  to  the  body  of  the  scapula. 
These  rare  lesions  are  called  fractures  of  the  surgical  neck  of  the  scapula. 
The  flattened  shoulder,  prominent  acromion,  and  loss  of  voluntary  mo- 
tion of  the  arm  make  the  lesion  resemble  axillary  dislocation  of  the  head 
of  the  humerus ;  but  the  easy  reduction  and  immediate  recurrence  of 
deformity,  the  crepitation  and  the  absence  of  the  humeral  head  in  the 
axillary  space,  establish  the  distinction.  The  sinking  of  the  outer  frag- 
ment of  the  scapula  with  the  attached  humerus  into  the  axillary  space 
may  mislead  the  careless  surgeon  into  the  belief  that  a  humeral  disloca- 
tion has  occurred.  The  treatment  resembles  that  for  fracture  of  the 
clavicle,  though  an  axillary  pad  to  keep  the  arm 
scapula  is  perhaps  more  essential  in  this  instance, 
placement  is  to  be  antagonized  by  a  short  sling  or 
elbow. 


out  and  steady  the 
The  downward  dis- 
bandao;e  to  lift  the 


Fractures  of  the  Humerus. 

These  injuries  are  conveniently  grouped  as  fractures  of  the  upper  end, 
fractures  of  the  shaft,  and  fractures  of  the  lower  end  of  the  bone. 

Fractures  of  the  Upper  Exd  of  the  Humerus. — The  usual  lines 
of  fracture  at  the  upper  extremity  of  the  humerus  are  through  the  ana- 
tomical neck  and  tuberosities ;  at  the  surgical  neck,  which  is  the  constric- 
tion with  indefinite  boundaries  seen  below  the  tuberosities ;  and  at  the 
line  of  the  main  epiphyseal  cartilage.     Fracture  of  the  surgical  neck  is 


Fig.  184. 


Fig.  185. 


Fracture  through  tuberosities  of  humerus 
with  head  united  to  the  shaft  at  a  lower 
level  than  normal.     (Stimson.) 


Specimen  of  fracture  of  the  surgical 
neck  of  the  humerus.    (Bryant.) 


the  most  common  of  these.  Fractures  of  the  head  alone,  of  the  anatomi- 
cal neck  alone,  and  of  the  tuberosities  alone  are  possible  injuries ;  but  are 
too  rare  in  occurrence  and  too  difficult  of  exact  clinical  recognition  to 
warrant  discussion  in  this  treatise.  The  existence  of  such  fracture  lines 
in  conjunction  with  multiple  splitting  of  the  upper  end  of  the  bone  is,  of 


J88 


DISEASES    AND    INJURIES    OF    BOXES. 


course,  not  so  unusual.  Detachment  of  a  portion  of  one  of  the  tuber- 
osities by  museuhir  action  happens  occasionally  as  an  accompaniment  of 
dislocation  of  the  head  of  the  humerus;  and  is,  in  fact,  a  lesion  very 
similar  to  what  has  been  elsewhere  descril)ed  as  "  sprain  fracture," 

Fractures  through  the  anatomical  neck  and  tubercles  frecjuently  show 
little  displacement,  because  the  fragments  are  impacted  or  are  held 
together  by  uutorn  periosteum.  There  is  no  evidence  that  fractures 
entirely  within  the  capsule  of  the  shoulder-joint  fail  to  unite,  or  that  the 
superior  fragment  acts  as  a  foreign  body  and  causes  violent  arthritis. 
Sometimes  the  lower  fragment  or  shaft  is  drawn  upward  by  the  deltoid 
muscle  in  such  a  manner  that  the  upper  fragment  or  head  becomes  united 
to  the  former  at  a  lower  level  than  normal,  and  gives  the  joint  the  appear- 
ance of  being  the  seat  of  an  unreduced  dislocation. 


Fig.  186. 


Fh;.  187. 


Diagrammatic  fracture  of  surgical  neck  of 
humerus.    (Gray.) 


Separation  of  upper  epiphysis  of 
humerus.     (Moore.) 


The  surgical  neck  of  the  humerus  is  frequently  broken  and  sometimes 
with  but  little  displacement.  Fissured  lines  may  extend  upward  within 
the  articular  capsule,  and  impaction  is  not  unusual.  Displacement  of  the 
end  of  the  lower  fragment  inward  seems  to  be  the  most  common  deform- 
ity. Separation  of  the  main  epiphysis,  which  consists  of  the  head  and 
tuberosities,  resembles  in  many  respects  fracture  of  the  surgical  neck  ; 
but  only  occurs  previous  to  the  twentieth  year  of  life.  When  displace- 
ment occurs  there  is  seen  on  the  front  of  the  shoulder,  an  inch  or  so  below 
the  acromion,  a  prominence  which  on  palpation  is  felt  to  be  a  smooth, 
slightly  convex  end  of  bone,  moving  with  rotation  of  the  elbow.  It  is 
the  upper  end  of  the  humeral  shaft.  Preternatural  mobility  and  soft 
crepitus  may  be  distinguished.  Union  of  fractures  of  the  surgical  neck 
and  of  epiphyseal  separations  occurs  in  six  to  eight  weeks,  and  is  followed 
by  good  results  if  displacement  has  been  corrected.  The  injury  to  the 
epiphyseal  cartilage  is  sometimes,  however,  followed  by  arrest  of  longi- 
tudinal growth  of  the  bone.  Occasionally,  the  upper  fragment  is  so 
rotated  by  the  scapular  muscles  that  its  under  surface  looks  forward  and 
outward.     In  such  cases  apposition  may  often  be  obtained  by  abducting 


FEACTURES    OF    THE    HUMERUS. 


389 


the  arm  and  cariying  the  elbow  up  alongside  of  head  until  the  lower 
fragment  becomes  interlocked  with  the  upper  one.  Coaptation  will  some- 
times be  maintained  after  this  manipulation  when  the  arm  is  gently 
depressed  again. 


Fig.  188. 


Epiphyseal  separation  at  upper  end  of  humerus.     (Bryaxt.) 

Diagnosis  of  Injuries  aboi'T  the  Shoulder-joint. — In  investi- 
gating traumatic  lesions  in  the  vicinity  of  the  shoulder,  recognition  of  the 
fact  that  fracture  exists  is  more  important  than  a  knowledge  of  the  exact 
variety  of  fracture.  The  relation  of  the  bony  prominences  to  each  other 
should  be  investigated  and  the  correspondence  of  such  relations  with  that 
on  the  normal  side  carefully  established.  Acupuncture  needles  may  be 
employed  in  obscure  cases  to  determine  the  location  of  the  bony  constitu- 
ents of  the  joint.  The  surgeon  should  grasp  the  head  of  the  humerus 
with  the  fingers  of  one  hand  while  he  rotates  the  arm  by  the  other  hand 
applied  to  the  elbow.  If  a  fracture  exists  between  these  two  points  the 
motion  given  to  the  lower  end  of  the  bone  will  not  be  transmitted  to  the 
head  unless  impaction  has  taken  place.  The  same  manipulation  will  in 
most  instances  of  fracture  develop  creiDitus*  especially  if  some  extension 
be  used  at  the  same  time  to  draw  the  overlapping  ends  into  contact. 

In  dislocation  of  the  head  of  the  humerus  the  shoulder  will  be  flattened, 
the  acromion  very  prominent  and  with  a  depression  below  it  into  which 
the  surgeon's  finger-tips  can  be  pushed  ;  the  elbow  will  be  abducted  from 
the  chest,  the  arm  roated  inward  and  the- head  of  the  humerus  noticeable 
by  palpation  in  its  abnormal  location,  which  is  usually  the  axilla  or  the 
fossa  just  below  the  clavicle.  In  addition  to  these  symptoms  voluntary 
motion  is  lost ;  passive  motion  greatly  restricted ;  it  is  impossible  to  place 
the  patient's  hand  on  the  opposite  shoulder  while  the  elbow  of  the  injured 
side  is  pressed  close  to  the  breast ;  the  long  axis  of  the  humerus  is  not 
directed  toward  the  glenoid  cavity  but  internally  to  it ;  the  head  of  the 
bone  is  felt  to  move  when  the  elbow  is  rotated ;  no  true  fracture  crepitus 
is  developed,  though  a  soft  rubbing  sensation  may  be  detected,  and  after 
reduction  the  deformity  does  not  occur  on  removing  restraint  from  the 
limb. 

When  the  head  of  the  humerus  is  in  its  normal  position  the  upper  por- 
tion of  a  straight  rod  laid  upon  the  outside  of  the  arm  from  shoulder  to 
elbow  will  be  half  an  inch,  an  inch,  or  perhaps  more  from  the  edge  of 
the  acromion ;  but  if  the  head  is  not  in  the  glenoid  cavity  the  rod  will 
touch  the  acromion  unless  very  great  swelling  of  the  soft  parts  happens 
to  be  present.     The  following  test  is  given  by  Hamilton :     Grasp  the 


890  DISEASES    AND    INJURIES    OF    BONES. 

top  of  the  shoulder  so  that  the  commissure  between  the  forefinger  and 
thumb  will  rest  upon  the  acromion  just  outside  its  articulation  with  the 
clavicle,  and  let  the  finger  and  thund)  fall  vertically  downward.  The 
anterior  digit  will,  if  the  bone  be  in  place,  rest  upon  the  centre  of  the 
head  as  it  projects  normally  in  front  of  the  acromion,  while  the  posterior 
digit  will  in  a  similar  manner  rest  upon  its  less  prominent  posterior  sur- 
face. If  the  surgeon  will  now  move  the  patient's  elbow  forward  so  as  to 
carry  the  head  of  the  humerus  backward,  he  will  feel  it  press  strongly 
against  the  posterior  digit,  thus  conclusively  proving  that  the  head  of  the 
humerus  is  in  its  normal  position,  for  if  dislocation  exists  the  humeral 
head  cannot  be  so  felt  by  this  manipulation. 

Fracture  of  the  neck  of  the  scapula  with  displacement  is,  according  to 
Hamilton,  the  only  injury  that  can  simulate  dislocation  during  the  appli- 
cation of  this  test.  Exclusion  of  this  unusual  fracture,  therefore,  renders 
the  above  tests  diagnostic  as  to  the  existence  or  non-existence  of  disloca- 
tion. Fracture  of  the  neck  of  the  scapula  is  distinguished  from  disloca- 
tion of  the  head  of  the  humerus  by  absence  of  rigidity  during  passive 
movement,  which  is  almost  unlimited  ;  by  crepitation,  and  by  the  imme- 
diate recurrence  of  deformity  when  pressure  which  has  pushed  the  arm 
upward  is  withdrawn. 

Fractures  of  the  head  and  of  the  anatomical  neck  of  the  humerus  are 
too  infrequent  and  too  obscure  of  diagnosis  to  require  further  mention 
than  has  been  previously  given.  Fracture  of  the  greater  tuberosity  is 
unusual  also,  except  as  a  complication  of  dislocation. 

In  epiphyseal  separation,  which  occurs  not  later  than  the  twentieth 
year,  the  head  of  the  bone  can  be  felt  in  its  normal  position  though  it 
does  not  move  with  the  shaft,  the  upper  end  of  which  lies  in  front  or  to 
the  inner  side  of  the  head.  Soft  crepitation  is  perceptible  when  the  sepa- 
rated surfaces  can  be  placed  in  apposition,  the  elbow  can  readily  be 
pressed  close  to  the  ribs,  though  the  arm  is  directed  somewhat  outward 
and  backward,  and  voluntary  motion  is  lost,  but  passive  mobility  in- 
creased. 

Fracture  of  the  surgical  neck  is  common,  and  is  therefore  the  injury  in 
this  region  which  most  frequently  requires  discrimination  from  dislocation. 
Displacement  similar  to  that  found  in  epiphyseal  separation,  the  easy 
demonstration  of  the  head  of  the  bone  in  its  normal  position,  preternatural 
mobility  and  crepitus  unless  impaction  exists,  and  immediate  recurrence 
of  deformity  upon  removal  or  support,  are  the  usual  features.  The  symp- 
toms of  fracture  of  the  surgical  neck  and  of  epiphyseal  separation  are 
very  similar,  and  differ  from  those  of  dislocation  in  almost  every  particu- 
lar except  that  in  all  three  injuries  voluntary  motion  is  lost.  In  disloca- 
tion this  is  due  to  destruction  of  the  articulation  and  the  entanglement  of 
the  humeral  head  in  its  abnormal  position,  which  circumstance  gives  an 
appearance  of  rigidity  to  the  limb.  In  fracture  or  epiphyseal  separation 
loss  of  active  motion  results  from  destruction  of  the  lever  through  which 
the  muscles  act,  hence  occurs  an  appearance  of  helpless  inactivity. 

Any  of  these  fractures  at  the  upper  end  of  the  humerus  may  be  com- 
plicated with  dislocation  of  the  scapulo-humeral  articulation.  The  symp- 
toms of  the  two  lesions  will  then  be  a  flat  shoulder,  prominent  acromion, 
and  abnormal  location  of  the  globular  head,  combined  with  abnormal 
mobility,  crepitus,  and  deformity  in  the  line  of  the  bone.  The  freedom 
of  passive  motion  and  the  ease  with  which  the  hand  can  be  placed  upon 
the  opposite  shoulder  while  the  elbow  is  pressed  to  the  ribs  will  differen- 
tiate the  case  from  uncomplicated  dislocation.     When  the  accompanying 


FRACTURES    OF    THE    HUMERUS. 


391 


Fig.  189. 


fracture  is  a  mere  detachment  of  the  greater  tuberosity  these  last  two 
symptoms  will  not  be  present.  When  none  of  the  injuries  just  detailed 
have  been  detected  and  fracture  of  the  clavicle,  acromion,  or  coracoid 
process  also  have  been  eliminated,  the  surgeon  is  justified  in  making  a 
diagnosis  of  sprain  or  of  contusion,  for  about  the  only  other  described 
injury  is  dislocation  of  the  long  tendon  of  the  biceps,  the  very  existence 
of  which  lesion  is  doubted  by  many. 

Treatment  of  Fractures  at  the  Upper  End  of  the  Humerus. 
— The  result  of  these  fractures,  if  of  ordinary  severity  and  if  displace- 
ment is  overcome,  is  usually  good ;  though  in  rheumatic  patients  a  certain 
degree  of  stiffness  often  remains  for  a  long  time,  even  when  the  joint  has 
not  been  invaded.  The  treatment  of  fractures  of  the  head,  anatomical 
neck,  and  tuberosities  consists  in  simple  restraint  of  motion,  induced  by 
carrying  a  broad  strip  of  adhesive  plaster  or  bandage  once  around  the 
arm  and  chest  and  placing  the  hand  and  wrist  in  a  sling.  Violent  move- 
ments to  verify  a  probable  diagnosis  should  be  avoided,  as  any  impaction 
existing  may  thus  be  destroyed  with  the  unfortunate  result  of  increasing 
displacement.     In  four  to  six  weeks  treatment  may  be  discontinued. 

Other  fractures  at  the  upper  end  of  the  humerus  are  best  dressed  by 
filling  up  the  hollow  of  the  axilla  with  a  folded  naj^kin  or  thin  compress, 
and  then,  after  replacing  the  fragments, 
securing  the  arm  against  the  chest  with 
the  elbow  carried  a  little  forward.  In 
this  manner  the  thorax  acts  as  a  splint 
to  which  the  arm  is  bound  by  means  of 
adhesive  plaster  or  a  bandage.  The 
forearm  may  be  laid  across  the  opposite 
mammary  region  as  in  treating  frac- 
tured clavicle,  or  may  be  simply  sup- 
ported in  a  sling  which  should  preferably 
be  applied  near  the  wrist  in  order  that 
the  weight  of  the  elbow  may  furnish 
some  slight  extending  force.  The  shoul- 
der-cap splint  is  usually  a  useless  and 
unnecessary  complication.  When  it  is 
deemed  necessary  that  greater  exten- 
sion should  be  exerted  a  Aveight  may  be 
attached  to  the  elbow  by  an  extension 
apparatus  of  adhesive  plaster  such  as  is 
used  for  continuous  traction  or  extension 
in  fracture  of  the  femur.  In  the  event 
of  the  upper  fragment  being  so  rotated 
outward  that  coaptation  cannot  be 
maintained  unless  the  lower  fragment  is 
carried  upward  and  outward,  it  becomes 
necessary  to  treat  the  fracture  with  the 
arm  strongly  abducted.  This  may  be 
done  by  using  a  triangular  splint,  of 
leather  or  other  firm  material,  with  a 
rounded  apex.  The  apex  should  be 
pushed  well  up  into  the  axilla  and  the 
legs  of  the  triangle  fixed  to  the  side  of 
the  chest  and  inner  aspect  of  the  arm  respectively.  Another  method  is  to 
put  the  patient  in  bed  and  by  means  of  an  extension  apparatus  of  adhesive 


Method  01  applying  extension  in 
fractures  of  the  humerus.  (Hamil- 
ton.) 


392  DISEASES    AND    INJURIES    OF    BONES. 

plaster,  a  pulley  and  a  weight  to  obtain  continuous  abduction  and  exten- 
sion of  the  limb.  An  elastic  cord  properly  attached  to  the  wall  of  the 
room  will  answer  the  same  purpose  as  tiie  weight.  Counter-extension 
can  be  exerted  by  elevating  the  foot  of  the  bed  or  by  fastening  the  patient 
to  the  head  of  the  bed  by  adhesive  plaster  attached  to  the  chest  and  shoul- 
der. In  such  instances  the  arm  usually  has  to  be  kept  at  an  angle  with 
the  long  axis  of  the  trunk  of  from  30  to  4")  degrees. 

The  (Iressing  may  be  discontinued  in  ordinary  cases  of  fracture  of  tlie 
upj^er  end  of  the  humerus  in  five  or  si.x  weeks. 

Gunshot  and  other  open  fractures  involving  the  shoulder-joint  may 
demand  excision,  but  conservative  antiseptic  measures  and  secondary  ex- 
cisions have  of  late  years  displaced  to  a  great  extent  primary  excisions. 
In  fractures  complicated  with  dislocation  an  attempt  to  reduce  the  dislo- 
cation should  be  made  at  once.  If  this  is  found  impossible,  the  fracture 
should  be  treated  and  renewed  etiorts  at  reduction  made  subsequent  to 
union  of  the  fracture.  If  there  is  definite  evidence  that  such  late  efforts 
will  be  unavailing,  even  with  the  advantage  of  leverage  gained  by  the 
united  bone,  endeavors  to  prevent  union  and  create  a  false  joint  at  the 
seat  of  fracture  are  justifiable.  The  disa])ility  due  to  old  fractures  com- 
plicated with  dislocation  may  sometimes  be  les.sened  by  excision  of  the 
head  or  the  upper  end  of  the  lower  fragment. 

Fractures  of  the  Shaft  of  the  Humerus. — Fracture  from  mus- 
cular violence  is  more  common  here  than  in  any  other  part  of  the  skeleton 
except  the  patella  and  olecranon.  Displacement  in  fractures  of  the  shaft 
depends  more  on  the  breaking  force  than  the  action  of  muscles.  The 
usual  characteristic  symptoms  of  fracture  are  present  and  easily  deter- 
mined. Involvement  of  the  vessels  and  nerves  in  the  injury  is  not  so 
very  uncommon.  AVrist-drop  from  palsy  due  to  pressure  upon  the  mus- 
culo-spiral  nerve,  and  gangrene  following  vascular  damage,  must  not  be 
hastily  referred  to  improper  treatment.  Union  occurs  among  children  in 
three  or  four  weeks,  among  adults  one  or  two  weeks  later.  Delayed 
union  and  non-union  happen  more  frequently  than  in  other  long  bones ; 
and  is  possibly  accounted  for  by  the  difficulty  of  completely  immobilizing 
the  limb  when  the  fracture  is  treated  with  the  elbow  flexed. 

Fig.  \'M<. 


Internal  angular  splint  with  changeable  angle. 

In  treating  these  lesions  the  surgeon  should  be  especially  on  the  al^rt 
to  overcome  rotary  displacement.  Such  deformity  can  be  detected  by 
observing  that  a  line  drawn  from  the  greater  tul)erosity  to  the  outer  con- 
dyle is  not  parallel  to  the  long  axis  of  the  bone  as  it  "should  be.  When 
much  swelling  is  present,  and  when  a  suspicion  of  complicating  injury  of 
vessels  or  nerves  exists,  it  is  wise  to  keep  the  patient  in  bed  a  few  days  and 
employ  simple  support  by  pillows  and  cushions,  lest  the  more  constricting 
dressing  be  accused  of  producing  gangrene  or  paralysis.  Few  fractures  of 
the  shaft  require  continuous  extension  by  weight  from  the  elbow.    Frac- 


FRACTURES    OF   THE    HUMERUS. 


393 


Fig.  191. 


tures  in  the  upper  half  of  the  shaft  are  well  treated,  as  are  fractures  of  the 
upper  end,  by  using  the  lateral  thoracic  wall  as  a  splint.  The  thin  axillary 
pad,  described  in  this  manner  of  dressing,  may  act  better  if  somewhat 
wedge-shaped  and  placed  with  its  base  downward. 

In  lesions  of  the  lower,  and  sometimes  in  those  of  the  upper  half,  an  in- 
ternal right-angle  splint,  with  or  wnthout  an  external  concave  splint  of 
pasteboard,  leather  or  gutta  percha,  makes  a  good  dressing.  The  internal 
splint  should  be  well  padded  at  the  elbow  or  have  an  opening  in  it  to  pre- 
vent pressure  on  the  internal  epicon- 
dyle.  The  elbow  should  not  be  drawn 
upward  by  the  sling  used  to  support 
the  forearm.  Sometimes  an  external 
angular  splint,  reaching  from  acromion 
to  wrist,  is  preferable.  At  other 
times  a  straight  external  splint  from 
shoulder  to  wrist  may  be  found  more 
effective  in  restraining  motion  at  the 
seat  of  fracture,  because  it  better  im- 
mobilizes the  elbow-joint.  The  forearm 
should  be  semi-prone  when  this  dress- 
ing is  employed.  The  gypsum  dressing 
is  often  satisfactory  after  primary  dis- 
placement and  swelling  have  been  re- 
moved. When  adopted  it  should  be 
applied,  with  the  elbow  flexed,  from  the 
hand  to  above  the  shoulder  with  a  few 
turns  of  the  saturated  bandage  passing  around  the  upper  part  of  the  chest. 
A  forearm  sling  completes  the  dressing. 

Fractures  of  the  Lower  End  of  the  Humerus. — The  principal 
fracture  lines  which  may  occur  at  the  lower  end  of  the  humerus  are  shown 
in  the  diagrams.  In  addition,  the  small  tubercle  on  the  external  condyle, 
sometimes  called  the  external  epicondyle,  may  be  detached,  and  in  very 
rare  instances  a  portion  of  the  articular  surface  of  the  bone  may  be  chipped 
off.  Of  course,  comminuted  fractures  following  no  definite  lines  may 
occur  here  as  elsewhere  in  the  skeleton. 


Splmt  foi  fiacture  of  shaft  of  humerus. 
(Bryant.) 


Fig.  192. 


Fig.  19.3. 


•/i       / 

Principal  fracture  lines  of  lower  end  of  humerus. 


In  studying  injuries  about  the  elbow%  it  should  be  remembered  that 
there  is  no  lateral  motion  between  the  humerus  and  the  bones  of  the  fore- 
When  the  elbow  is  semi-flexed  an  apparent  lateral  motion  is  ob- 


arm. 


servable.  It  really  takes  place  at  the  shoulder  and  not  at  the  elbow, 
which  is  a  hinge  joint  alone.  Flexion  and  extension  of  the  joint  proper 
and  rotation  of  the  head  of  the  radius  are  the  only  possible  motions  of 


394 


DISEASES    AND    INJURIES    OF    BONES. 


the  healthy  articulation.     Lateral  mobility  at  the  elbow  means  fracture 
or  some  other  organic  change  in  the  constituents  of  the  joint. 

Fracture  above  the  condyles  may  be  mistaken  for  dislocation  of  the 
bones  of  the  forearm,  and  if  complicated  with  vertical  splitting  may  involve 
the  elbow-joint.     The  most  frequent  displacement  is  projection  of    the 


Fig.  194. 


Fig.  195. 


Diagrammatic  supra-condyloid  fracture  of  the  humerus.     (Gray.) 

upper  fragment  iu  front  of  the  lower  with  angular  deviation  in  the  line 
of  the  limb.  This,  if  uncorrected,  will  greatly  impair  the  future  utility 
of  the  joint.  It  is  the  prominence  given  the  olecranon  by  this  displace- 
ment that  creates  a  resemblance  to  dislocation.  The  normal  relation  of 
the  olecranon  to  the  condyles,  the  natural  character  of  the  joint  motions, 
the  crepitus  developed  when  extension  is  exerted  on  the  limb,  and  the 
recurrence  of  deformity,  establish  the  diagnosis. 

Separation  of  the  main   lower  epiphysis,  which,  though  small,  includes 
both  condyles,  is  rare.     In  deformity,  diagnosis  and  treatment,  the  injury 

differs  little  from  supracondyloid  fracture. 
This  conjugal  cartilage  ossifies  about  the 
sixteenth  year.  The  prominent  tubercle  on 
the  internal  condyle,  called  the  epitrochlea 
or  internal  epicondyle,  may  be  the  subject 
of  epiphyseal  separation  or  be  broken  off" 
with  or  without  a  small  portion  of  the  bone 
at  its  base.  The  line  of  fracture  is  entirely 
without  the  limits  of  the  joint ;  hence,  the 
articular  motions  are  unimpaired  unless  by 
spasm  or  fear  of  pain.  Downward  and 
forward  displacement  of  the  fragment  oc- 
curs when  its  fascial  envelope  is  sufficiently 
disturbed  to  permit  the  influence  of  muscular  traction.  Simultaneous 
injury  to  the  ulnar  nerve  lying  in  the  groove  behind  the  epicondyle  is 
possible.  Abnormal  mobility  and  crepitation  are  easily  detected  by  grasp- 


Epiphyseal  fracture  of  lower  end 
of  the  humerus.     (Bryant.) 


FRACTURES    OF    THE    HUMERUS. 


395 


ing  the  tubercle  in  the  fingers.  This,  which  is  likewise  developed  by  a 
distinct  ossific  centre  on  the  outer  condyle,  may  in  rare  instances  be 
detached. 

Fractures  separating  either  of  the  condyles  from  the  shaft  necessarily 
involve  the  joint,  and  hence  are  very  important  injuries.     Such  fractures 


Fig.  19fi. 


Fig.  197. 


Fig.  198. 


Fracture  above  condyles  of  hume- 
rus. (Stimson.) 


Xormal  angle  of  bones  of 

forearm.     (Allis.) 


/ 


are  common.     The  essential  components  of  the  elbow  / 

hinge  are  the  ulnar  aud  the  articular  surface  of  the  in-  / 
ternal  condyle.  Hence,  fractures  of  the  inner  condyle  / 
are  especially  dangerous  to  the  future  integrity  of  / 
joint  mobility.  The  ulnar  joins  the  humerus  in  such  / 
a  way  that  the  axes  of  the  two  bones  form  a  diverg- 
ent angle.  This  outward  deflection  of  the  forearm  I 
gives  the  "  carrying  function  "  to  the  limb,  by  which  i 
the  hand  when  hanging  by  the  side  is  enabled  to 
carry  burdens  without  striking  the  thigh.  Loss  of  Outward  deflection  of 
this  angle  by  ascent  of  the  internal  condyle  or  descent  forearm.  (Stimsox.) 
of  the  external  condyle  after  fractures,  greatly  impairs 
theusefulness  of  the' limb.  Such  displacements  are  very  common,  because 
the  line  of  fracture  usually  runs  obliquely  from  the  margin  of  the  base  of 
one  condyle  down  into  the  articular  surface  of  the  same.  The  condyloid 
fragment  in  fracture  of  the  inner  condyle  is  usually  displaced  upward  and 
backward,  and  drags  the  attached  ulna  with  it,  thus  destroying  the 
divergent  angle  at  the  elbow.  It  is  said  that  a  quarter-inch  displace- 
ment upward  will  destroy  this  angular  deviation.  The  anterior  or  pos- 
terior right-angle  splint  often  used  to  dress  this  fracture  is  accused,  by 
Dr.  0.  H.  Allis,  of  Philadelphia,  of  being  a  frequent  cause  of  this  de- 
formity. He  probably  is  right.  He  says  that  such  a  splint  bandaged 
upon  the  flexed  elbow  tends  to  raise  the  ulna  till  it  lies  on  the  same  plane 
as  the  radius,  while  it  normally  lies  below  that  bone  when  the  elbow  is 
bent.     The    displacement    in  fractures  of   the  outer    condyle    is   often 


396 


DISEASES    AND    INJURIES    OF    BONES. 


upward,  thus  increasing  the  outward  angle  at  the  elbow;  but  the  radius 
with  the  attached  condyloid  fragment  may,  according  to  Allis,  be  forced 


Fid.  iy9. 


Fractureof  internal  condyle.    (Hamilton.)       Fracture  of  external  cimdyle.    (Hamilton. 

Fig.  201. 


Deformity  after  fracture  at  lower  end  of  humerus.     "  Gunstock  deformity."    (Ali.is.) 
Fig.  2()2.  Fig.  20.3. 


Epiphyseal  separation  or  fracture  above 
condyle,  showing  possibility  of  deformity 
by  tilting  the  lower  fragment.     (Allis.) 


Fracture  of  external  condyle  showing 
similar  possibility  of  deformity.  (Al- 
lis.) 


FRACTURES    OF    THE    HUMERUS, 


397 


down  by  rectangular  splints  till  it  reaches  the  level  of  the  ulna,  so  as  to 
cause  a  loss  of  the  divergent  angle  at  the  elbow.     Dr.  Allis  thinks  that 


Fig.  204. 


Fig.  205. 


Fig.  206. 


Fig.  204. — Diifering  planes  of  radius  and  ulna.     (Allis). 

Fig.  205. — Relation  of  radius  and  ulna  to  humerus  in  fracture  of  internal  condyle, 
showing  ease  with  which  ulna  and  broken  condyle  can  be  forced  up  by  splint  and  band- 
age, and  thus  destroy  carrying  function  of  arm.     (Allis.) 

epiphyseal  separation  and  fractures  above  the  condyles  may  show  similar 
distortion  from  the  use  of  rectangular  splints.  Condyloid  fractures  are 
occasionally  associated  with  partial  or  complete  dislocation  of  one  or  both 
forearm  bones. 

The  existence  of  mobility  and  crepitus  is  to  be  determined  by  grasping 
the  lower  end  of  the  humerus  and  the  suspected  condyle  Avith  the  fingers 
of  the  two  hands  and  endeavoring  to  move  the  condyle  alternately  back- 
ward and  forward.  In  the  fully  extended 
normal  articulation  a  line  joining  the  two 
epicondyles  crosses  the  tip  of  the  olecranon, 
but  as  flexion  is  made  the  olecranon  sinks 
below  this  line.  The  position  of  the  head  of 
the  radius,  one-half  inch  below  the  external 
epicondyle,  should  also  be  recollected  in 
order  to  differentiate  dislocation  of  this  bone. 
If  the  surgeon  places  a  finger  at  this  point 
and  then  rotates  the  patient's  hand,  the  head 
of  the  radius  will  be  felt  rolling  under  the 
integument.  The  transverse  diameter  of  the 
lower  end  of  the  humerus  is  usually  increased 
in  condyloid  fracture,  because  of  the  ob- 
liquity of  the  line  of  fracture  and  the  common 
tendency  in  both  fractures  to  upward  displace- 
ment ;  but  it  is  often  difficult  to  be  certain  of 
this  widening.  When  backward  displacement 
has  occurred  after  fracture  of  the  internal 
condyle  the  prominent  olecranon  during  flex- 
ion and  the  disappearance  of  this  projection 
during  extension  greatly  resemble  backward 
dislocation  of  the  bones  of  the  forearm. 

Union  of  condyloid  fractures  occurs  in  four  or  five  weeks,  but  unreduced, 
displacements,  masses  of  callus,  and  the  sequences  of  secondary  synovitis 
often  leave  much  functional  disabilitv. 


lutercondyloid  fracture  of  the 
humerus.     (Stijison.) 


398  DISEASES    AND    INJURIES    OF    BONES. 

The  term  iutercoudyloid  is  applied  to  those  fractures  in  which  the  con- 
dyles are  split  apart  and  at  the  same  time  are  separated  from  the  shaft. 
The  fracture  lines  may  he  exceedingly -diverse  in  direction,  hut  in  simple 
cases  assume  an  irregular  T  or  Y  shape.  In  intercondyloid  fractures, 
which  are,  however,  not  very  common,  the  joint  is,  of  course,  implicated; 
and  very  often  great  damage  to  the  soft  parts  co-exists.  Separation  of 
the  condyles  with  the  olecranon  forced  up  between  them  is  a  not  unusual 
displacement.  Great  distortion  of  the  joint,  increased  width  of  the 
lower  end  of  the  humerus,  and  crepitation  when  the  fractured  surfaces 
are  brought  into  contact  render  the  diagnosis  evident. 

Diagnosis  of  Fractures  at  the  Lower  End  of  the  Humerus. — 
The  points  in  the  diagnosis  of  fractures  of  the  lower  end  of  the  humerus 
need  recapitulation.  Normally,  the  head  of  the  radius  is  about  half  an 
inch  below  the  external  epicondyle,  and  unless  the  shaft  of  the  radius  is 
broken  moves  when  the  hand  is  rotated.  With  an  extended  forearm  the 
two  epicondyles  and  the  tip  of  the  olecranon  are  on  a  level,  but  as  the 
elbow  is  flexed  the  olecranon  sinks  below  this  horizontal  line. 

8upra-condyloid  fracture  with  the  ordinary  backward  displacement  of 
the  lower  fragment  shows  unusual  projection  of  the  olecranon  and  triceps 
tendon,  increased  by  straightening  the  elbow ;  correction  of  deformity 
when  traction  is  made  upon  the  forearm,  with  recurrence  of  the  same 
when  the  traction  ceases  and  the  elbow  is  bent ;  motion  and  crepitus  above 
the  joint ;  free  mobility  at  the  joint  which  may,  however,  be  limited  by 
swelling  or  spasm ;  normal  relation  of  olecranon  and  epicondyles.  In 
backward  dislocation  of  the  bones  of  the  forearm  the  unusual  projection 
of  the  olecranon  and  triceps  tendon  is  diminished  by  straightening  the 
elbow,  and  the  point  of  the  olecranon  rises  above  the  level  of  the  epicon- 
dyles ;  when  the  deformity  is  reduced  there  is  a  distinct  snap  and  recur- 
rence of  distortion  does  not  readily  recur ;  no  motion  or  crepitus  can  be 
developed  above  the  joint,  though  joint  frictien  may  simulate  fracture 
crepitus  ;  the  normal  articular  movements  are  almost  abolished  and  the 
joint  is  fixed,  though  some  abnormal  lateral  motion  may  be  possible  ;  the 
relative  position  of  the  epicondyles  and  olecranon  is  altered  ;  the  head  of 
the  radius  is  not  in  its  proper  situation  ;  the  distance  between  the  epicon- 
dyles and  the  corresponding  styloid  processes  at  the  wrist  is  decreased ; 
and  the  lower  end  of  the  humerus  feels  smoother  and  wider  than  the  lower 
end  of  the  shaft  in  case  of  fracture. 

When  the  lower  fragment  is  displaced  forward  the  question  of  diagnosis 
is  easily  settled,  because  forward  dislocation  of  the  forearm  is  exceedingly 
rare  and  the  symptoms  characteristic. 

Fracture  of  the  internal  condyle  is  diagnosticated  by  crepitus  and 
independent  mobility  ;  lateral  mobility  at  the  elbow-joint  when  the  fore- 
arm is  extended ;  and  in  addition,  when  displacement  is  present,  change 
in  the  divergent  angle  of  the  elbow  and  alteration  in  the  horizoutality  of 
the  line  drawn  across  the  back  of  the  articulation  joining  the  epicondyles 
and  olecranon.  If  dislocation  of  the  head  of  the  radius  coexists,  the  head 
of  that  bone  will  probably  be  discovered  behind  the  external  condyle, 
and  the  internal  condyloid  ridge  of  the  humerus  will  be  felt  to  termi- 
nate abruptly  at  the  line  of  condyloid  fracture.  In  fracture  of  the 
external  condyle,  crepitation,  independent  mobility,  alteration  of  the 
normal  lateral  deviation  of  the  axis  of  the  limb  at  the  elbow,  change  of 
relation  with  the  other  condyle  and  olecranon,  but  normal  relation  to  the 
head  of  the  radius,  will  sei've  to  indicate  the  nature  of  the  lesion. 


FEACTUEES    OF    THE    HUMEEUS. 


899 


The  relation  to  the  head  of  the  radius  should  be  carefully  studied  when 
outward  dislocation  of  the  radius  and  ulna  is  a  question  to  be  determined. 

In  suspected  intercondyloid  fractures,  great  deformity  with  distortion 
of  relation  of  the  bony  landmarks,  increase  in  width  of  the  lower  end  of 
the  humerus,  independent  mobility  of  the  condyles  and  between  the  con- 
dyles and  shaft,  and  crepitation,  especially  noticeable  when  the  olecranon 
is  drawn  down  and  the  condyles  pressed  together,  are  the  symptoms  to  be 
sought. 

Treatment  of  Fractures  at  the  Lower  End  of  the  Humerus. — 
It  has  been  the  general  custom  for  the  most  part  to  treat  these  fractures 
in  the  flexed  position  with  anterior  or  internal  angular  wooden  splints,  or 
Avith  posterior  augular  trough-like  splints,  made  of  felt,  tin,  gypsum,  or 
similar  material.  This  is  usually  an  error.  The  best  results  will  generally 
be  obtained  by  keeping  the  joint  extended  or  nearly  so  during  the  time 
that  displacement  is  likely  to  occur.     Ankylosis  in  the  extended  posture 


Fig.  207. 


Fig.  208. 


Anterior  angular  splint,  with  changeable  angle. 

Fig.  209. 


Posterior  angular  trough. 


Deviating  splint  for  fractures  through  the 
eondvles  of  the  humerus. 


is,  I  admit,  very  undesirable,  but,  unless  permanent  ankylosis  is  very  cer- 
tain to  occur,  disability  from  the  ■"  gunstock  "  deformity  is  to  be  guarded 
against  by  keeping  the  joint  extended.  Fractures  of  the  epicondyles, 
some  fractures  of  the  external  condyle,  fracture  of  the  internal  condyle 
with  backward  luxation  of  the  radius  and  ulna,  and  bad  intercondyloid 
fractures,  may  perhaps  give  better  results  when  the  flexed  position  is 
adopted,  but  for  the  great  majority  of  cases  the  extended  posture  is  better. 
The  dressing,  then,  for  fractures  at  the  lower  end  of  the  humerus  consists 
of  a  straight  wooden  splint,  twelve  or  fourteen  inches  long,  placed  upon 
the  anterior  surface  of  the  arm  and  forearm,  with  a  little  extra  padding 
at  the  bend  of  the  elbow  if  complete  extension  of  the  joint  is  not  desired. 
The  application  of  a  moulded  gypsum  splint  to  the  anterior  or  posterior 
surface,  or  to  the  entire  circumference  of  the  arm,  is  sometimes  preferable. 
Four  weeks  or  less  is  usually  long  enough  to  retain  the  splint  upon  the 
limb.     In  all  cases  the  surgeon  should  see  that  the  outward  deflection  of 


400  DISEASES    AND    INJURIES    OF    BONES. 

the  forearm,  due  to  the  obtuse  angle  between  the  axes  of  the  arm  and 
forearm,  is  maintained.  It  is  usually  best  to  have  the  straight  splint  cut 
so  as  to  make  a  slight  outward  deflection  between  the  arcs  of  the  upper 
and  lower  portions.  I  have  often  made  such  splints  from  a  strip  of 
board  with  my  pocket-knife.  It  is  well  to  comj)are  the  patient's  arras,  as 
the  normal  outward  deflection  varies  in  individuals.  If  the  position  of 
extension  is  uncomfortable,  or  if  there  is  reason  to  believe  that  permanent 
ankylosis  is  about  to  occur,  the  straight  splint  may  be  removed  at  the 
end  of  two  weeks  and  the  elbow  carefully  flexed  to  nearly  a  right  angle. 
Should  the  fragments  remain  in  good  position  and  no  tendency  to  recur- 
rence of  deformity  be  present,  the  subsequent  treatment  may  be  con- 
ducted with  an  angular  splint. 

In  very  bad  intercondyloid  fractures  and  fractures  involving  the  radius 
and  ulna  as  well  as  the  humerus,  ankylosis  will  almost  certainly  occur; 
hence  the  flexed  position  here  should  be  adopted  more  frequently  than  in 
other  cases.  Continuous  weight-extension  may  become  necessary  to  keep 
the  fragments  in  position.  Excision  of  the  joint  may  be  demanded  in 
such  fractures,  if  open.  It  is  better  in  such  excisions  to  avoid,  if  practi- 
cable, removal  of  the  upper  ends  of  radius  and  ulna,  because  otherwise 
the  insertions  of  the  great  muscles  are  disturbed.  Passive  motion  should 
not  be  made  before  the  end  of  three  or  four  weeks,  and  not  then  if  it 
causes  pain.  The  moderate  stiffness,  usually  left  even  in  favorable  cases, 
will  disappear  in  the  course  of  a  few  weeks  after  removal  of  the  splints, 
especially  if  active  and  passive  motions  accompanied  by  friction  be 
employed.  If  inflammatory  involvement  of  the  joint  has  taken  place 
early  passive  motion  will  do  no  good  but  probably  much  harm. 


Fractures  of  the  Bones  of  the  Forearm. 

Fracture  of  both  bones  of  the  forearm  near  the  middle  is  quite  com- 
mon, but  fracture  of  the  shaft  of  either  bone  alone  is  unusual.  When 
the  radius  alone  is  broken  the  lesion  is  nearly  always  situated  near  its 
lower  end,  while  the  ulna  when  broken  alone  nearly  always  suflfers  such 
lesion  at  the  upper  end. 

The  clinical  phases  and  the  diagnosis  of  fractures  of  the  forearm  will 
be  better  appreciated  if  lesions  of  similar  parts  of  the  ulna  and  radius  are 
discussed  together. 

Fractukes  near  the  Elbow-joint. — Hence  I  shall  speak  first  of 
fractures  near  the  elbow-joint.  This  is  the  method  adopted  by  Stimson  in 
his  elaborate  work  on  fractures,  from  which,  I  may  say  in  passing,  much 
of  the  material  used  in  this  section  on  fractures  has  been  obtained. 

Fracture  of  the  Olecranon. — Direct  violence  may  cause  the  ole- 
cranon to  be  broken  from  the  shaft  of  the  ulna,  but  it  is  probable  that  a 
great  majority  of  these  fractures  are.  due  to  a  leverage  action  consequent 
upon  the  triceps  holding  the  process  firmly  against  the  lower  end  of  the 
humerus  at  the  time  the  impinging  force  is  applied  to  the  forearm.  The 
bone  snaps  in  such  cases  as  a  stick  is  broken  by  the  hands  across  one's 
knee.  Muscular  contraction  alone  seldom  causes  this  fracture.  The 
location  of  fracture  varies,  but  most  commonly  is  near  the  middle  of  the 
process,  where  there  is  a  narrowing.  The  epiphyseal  cartilage,  which 
ossifies  about  the  sixteenth  year  of  life,  is  placed  near  the  middle  of  the 
olecranon ;  therefore,  supposed  fractures  in  young  persons  may  really  be 


FRACTURES  OF  BONES  OF  THE  FOREARM. 


401 


instances  of  diastasis  or  epiphyseal  separation.  The  triceps  muscle  tends 
to  displace  the  upper  fragment  upward,  but  the  process  is  so  attached  to 
the  humerus  by  ligaments,  and  the  tendinous  expansion  of  the  muscle  so 
unsheathes  it  and  the  adjacent  part  of  the  ulna  that  not  much  separation 
occurs  unless  the  forearm  is  flexed.  In  fact  in  many  instances  no  marked 
displacement  takes  place  even  in  flexion,  because  the  fragments  are  bound 
together  by  the  untorn  aponeurosis.  Under  the  opposite  conditions  a 
separation  of  as  much  as  two  and  a  half  inches  is  said  to  be  possible,  but 
this  probably  refers  to  the  joint  in  a  flexed  or  semiflexed  position.  The 
intra-articular  efliision  that  frequently  arises  and  the  tendency  of  the 
biceps  and  anterior  brachial  muscles  to  draw  up  the  forearm,  and  thus 
crowd  the  humerus  into  the  gap  between  the  ulnar  shaft  and  olecranon, 
probably  have  an  influence  in  causing  separation  of  the  fragments. 


Fig.  210. 


Fig.  211. 


Diagrammatic  fracture  of  olecranon.    (Gray.)  Fi-acture  of  olecranon.    (Erichsen.) 


The  symptoms  are  localized  pain  and  swelling,  lateral  mobility  and 
crepitus,  combined  with  more  or  less  loss  of  power  to  extend  the  fore- 
arm, and  with,  in  some  cases,  a  noticeable  depression  at  the  seat  of  fracture. 
The  last  two  symptoms  vary  greatly  with  the  degree  of  laceration  of  the 
fibrous  envelope  of  the  bone.  The  development  of  crepitus  may  require 
the  fully  extended  position  of  the  joint  in  order  to  obtain  contact  of  the 
bony  surfaces.  If  local  pain  and  impaired  extension  power  alone  are 
present,  the  case  should  be  treated  as  an  instance  of  fracture  until  the 
subsequent  history  disproves  the  suspicion. 

Union  may  be  bony,  but  is  generally  fibrous.  A  comparatively  long 
fibrous  bond  gives  but  a  moderate  disability,  if  there  coexist  no  adhesions 
of  the  olecranon  to  the  humerus  and  no  intra-articular  fibrous  obstruc- 
tion. This  is  due  to  the  fact  that  powerful  and  extensive  flexion  is  a 
more  important  function  of  the  elbow  than  complete  extension.  Ununited 
fracture  is  not  very  infrequent. 

In  ordinary  cases  cure  takes  place  in  about  four  weeks,  and  though  the 
joint  is  necessarily  involved,  there  is  no  tendency  to  ankylosis  of  the 
elbow. 

When  separation  of  the  fragments  is  present  the  injury  should  be 
treated  with  a  splint  to  keep  the  elbow  extended  to  that  degree  which  is 
seen  when  the  arm  hangs  passively  at  the  side.     As  ankylosis  is  not  to 

26 


402 


DISEASES    AND    INJURIES    OF    BONES. 


be  anticipated,  the  most  accurate  coaptation  possible  is  to  be  sought.  This 
is  obtainable  only  by  the  extended  posture ;  but  the  extension  must  not 
be  so  excessive  as  to  bend  the  joint  backward,  which  is  possible  when  the 
niirnuil  check  to  sucli  motion  ijiven  bv  the  olecranon  is  destroyed  bv  frac- 


Vu..  212. 


Adhesive  strip  applied  t^ 


XKW.) 


ture.  The  upper  fragment  may  be  steadied  or  pulled  down  if  necessary 
by  a  strip  of  adhesive  plaster  so  apjilied  above  it  that  the  ends  cross  each 
other  upon  the  forearm.  An  anterior  straight  splint  of  wood  or  metal  or 
a  circular  gypsum  dressing,  leaving  the  elbow  uncovered,  is  then  applied 
from  the  upper  third  of  the  arm  to  the  lower  third  of  the  forearm.     If 

Fig.  21.-^. 


Fracture  of  olecranon  treated  in  extendeil  position.     (A(;xew.) 


it  is  impossible  to  bring  the  fragments  together  by  extension  alone,  the 
upper  fragment  may  be  drawn  down  by  a  single  steel  hook,  similar  to 
Malgaigne's  double  patella  hooks,  inserted  into  the  tendon  just  al)ove  the 
olecranon  and  attached  below  to  the  skin  and  fascia  covering  the  ulna, 
or  to  the  gypsum  dressing  which  is  applied  to  keep  the  elbow  extended. 
Tenotomy  of  the  triceps  tendon  would  be  justifiable  to  overcome  upward 
displacement.  The  hook  should  not  be  api)lied  for  three  or  four  days 
until  the  inflammation  immediately  following  the  injury  has  subsided, 
but  should  be  retained  in  position  for  four  weeks.  If  there  is  much  pri- 
mary synovial  effusion  into  the  joint,  increasing  displacement,  aspiration 
is  proper.  When  violent  reaction  occurs  and  ankylosis  seems  probable, 
passive  motion  may  be  cautiously  made  after  three  weeks,  but  is  to  be 
omitted  if  it  causes  inflammatory  reaction.  When  there  is  little  tendency 
to  separation  and  flexion  does  not  increa-se  the  displacement,  the  limb 
mav  be  treated  in  a  semi-flexed  position  if  extension  causes  discomfort. 
When  great  disability  has  resulted  from  long  fibrous  union,  great  im- 
provement has  been  obtained  by  exposing  the  bone,  freshening  the  ends, 
and  fastening  the  fragments  together  by  wire  sutures  introduced  so  as 
not  to  penetrate  the  joint.  This  procedure  is  justifiable  under  exceptional 
circumstances  if  done  antiseptically. 


FRACTURES  OF  BONES  OF  THE  FOREARM. 


403 


Fracture  of  the  coronoid  process  is  very  rare  except  as  a  complication  of 
backward  luxation  of  the  ulna  or  of  radius  and  ulna  together;  when  the 
process  is  liable  to  be  broken  off  by  being  driven  against 
the  articular  surface  of  the  humerus.     The  symptoms  Fig.  2ii. 

are  the  presence  of  a  small  movable  body  in  the  line 
of  the  tendon  of  the  anterior  brachial  muscle,  crepita- 
tion, and  usually  the  symptoms  of  dislocation  of  the 
forearm.  Displacement  from  muscular  contraction  is 
impossible,  unless  the  line  of  fracture  be  below  the 
base  of  the  process,  for  the  tendon  is  not  inserted  upon 
the  apex  of  the  coronoid  process.  A  similar  reason 
proves  the  supposed  detachment  of  this  apophysis  by 
muscular  contraction  an  error.  Treatment  consists  in 
immobilization  with  a  splint  or  the  gypsum  bandage 
for  a  couple  of  weeks  with  the  elbow  flexed  at  a  right  Fracture  of  coro- 
angle  or  less.  A  sling  should  then  be  worn  for  ten  noid  process,  and 
days  or  two  weeks  longer.  head     of     radius. 

Fractures  of  the  Head  and  Xeck  of  the  (Bryant.) 
Eadius. — Of  these  rare  injuries  little  is  known.  A 
splitting  off  of  a  part  of  the  articular  surface  of  the  head  with  the  line 
of  fracture  running  down  the  neck  is  perhaps  the  most  common  form, 
and  is  observed  in  connection  with  coronoid  fracture  of  the  ulna.  The 
fracture  may  be  entirely  within  the  joint ;  hence  synovitis  and  defect  in 
bony  union  might  be  expected.  Loss  of  power  of  rotation,  crepitation, 
the  presence  of  a  movable  fragment,  and  an  apparent  widening  of  the 
head  of  the  radius  are  the  symptoms  likely  to  aid  in  the  diagnosis.  The 
radius  may  also  be  broken  at  the  neck  just  above  the  bicipital  tubercle. 
Immobilization  for  three  or  four  weeks  in  the  flexed  and  supine  position, 
which  relaxes  the  biceps,  should  be  the  treatment. 

Fractures  Near  the  Middle  of  the  Forearm.     Fracture  of  the 
Shaft  of  Both  Bones. — When  the  radius  and  ulna  sustain  simultaneous 


Fig.  215. 


Union,  with  slight  lateral  displacement,  of  fracture  of  radius  and  ulna. 


fracture  of  the  shaft  it  is  usually  found  that  direct  violence  has  caused 
the  injury;  and  as  a  rule  the  radial  fracture  is  nearer  the  elbow  than  is 
the  ulnar  fracture.  Fractures  from  muscular  contraction  are  occasionally 
seen.  Green-stick  fracture  is  not  uncommon.  Angular  displacement 
toward  the  interosseous  space,  overriding  and  rotary  displacement  of  the 
radius  are  sources  of  deformity.  The  overriding  may  shorten  the  limb 
two  or  three  inches.  When  the  radial  fracture  is  above  the  insertion  of 
the  round  pronator  muscle,  the  short  supinator  and  the  biceps,  which  is 
also  a  supinator,  have  unopposed  action  ;  hence  the  upper  part  of  the 
bone  is  supinated,  and  the  lower  portion,  if  it  is  kept  pronated  by  the 
splints  will  unite  with  rotary  deviation.  To  avoid  this  the  hand  should 
be  kept  supine  by  the  splints. 


404 


DISEASES    AND    INJURIES    OF    BONES. 


Fig.  21(5. 


The  loss  of  rigidity  of  the  limb,  crepitus,  and  abnormal  mobility  render 
the  diagnosis  easy.  Union  occurs  in  about  four  weeks,  but  a  high  grade 
of  inflammation  is  not  an  infrequent  complication.  Gangrene  from  con- 
stricting dressings  must  be  remembered  as  a  possible  danger,  to  which 
attention  may  not  be  called  by  any  discomfort  felt  by  the  patient.  The 
comparative  frequency  of  these  complications  probably  arises  from  the 
usual  causation  of  the  fracture  by  direct  violence.  The  primary  bandage 
under  the  splints  is  to  be  especially  avoided  in  these  injuries.  When  the 
two  fractures  are  directly  opposite  eacii  other,  when  great  laceration  or 
irritation  of  the  interosseous  membrane  and  fibrous  tissue  has  occurred, 
and  particularly  when  inward  angular  deformity  is  permitted  to  remain 
uncorrected,  normal  pronatiim  and  supination  are  liable  to  be  diminished 
or  destroyed  by  an  osseous  l)ridge  soldering  the  radius  and  ulna  together, 
or  by  a  protuberance  of  one  or  both  bones.  The  prognosis  in  uncompli- 
cated cases  is  good,  though  delay  or  failure  in 
union  is  not  very  infrequent.  After  replacement 
of  the  fragments  has  been  obtained  by  extension 
and  counter-extension  and  by  pressure  of  the  fin- 
gers in  the  space  between  the  two  bones,  the  limb 
should  be  placed  in  the  supine  position,  that  is, 
with  the  palm  of  the  hand  upward,  and  so  main- 
tained by  splints  until  consolidation  has  occurred. 
The  semi-supine  position  is  often  adopted,  but  as  full 
sujjination  is  required  to  prevent  rotary  deformity 
of  the  radius  when  it  is  broken  above  the  insertion 
of  the  round  pronator,  it  is  safer  to  teach  the 
adoption  of  complete  supination  for  all  cases  of 
fracture  of  the  shaft.  Such  a  position  gives  be- 
tween the  radius  and  ulna  almost,  if  not  quite,  as 
much  space  as  the  serai-supine  position,  and  hence 
is  as  efficient  in  preventing  loss  of  rotation  by 
bridges  of  callus. 

The  supine  position  is  most  conveniently  main- 
tained by  the  use  of  either  a  right  angle  wooden 
or  metal  splint  applied  to  the  iiexor  surface  of  the 
limb  from  the  middle  of  the  upper  arm  to  the  root 
of  the  fingers,  or  a  right  angle  trough  similarly 
fitted  to  the  extensor  surface  of  the  arm  and  fore- 
arm. A  straight  palmar  and  dorsal  splint  applied 
together  and  extending  from  elbow  to  fingers  will 
scarcely  prevent  the  limb  assuming  the  semi-supine 
position,  which  is  more  convenient  and  comfortable 
to  the  patient  than  complete  supination.  After  partial  consolidation  has 
occurred,  say  at  the  end  of  two  weeks,  the  two  straight  splints  may  be 
substituted  for  the  angular  one,  since  at  that  time  the  risk  of  rotary  dis- 
tortion is  no  longer  great.  In  fractures  below  the  insertion  of  the  round 
pronator  such  splints  may  be  used  from  the  beginning  of  the  treatment, 
but  must  be  wider  than  the  arm  so  that  the  bandage  shall  not  press 
the  bones  together  at  the  site  of  fracture.  The  palmar  .splint  is  made 
more  comfortable  by  having  the  distal  end  cut  off  obliquely  and  well 
padded  for  the  fingers  to  close  over  it. 

In  all  these  fractures  the  sling  should  be  broad  enough  to  support  botk 
hand  and  forearm.  A  narrow  sling  supporting  one  part  only  is  liable  to 
permit  sagging  and  angular  deformity.     This  is  especially  so  when  the 


Angular  displacement 
iind  union  between  bones 
in  fracture  of  radius  and 
ulna.     (Stimsos.) 


FRACTURES  OF  BOXES  OF  THE  FOREARM. 


405 


palmar  and  dorsal  splints  are  employed.  The  use  of  a  narrow  compress 
under  the  splint  to  prevent  encroachment  of  the  fragments  upon  the  inter- 
osseous space  is  either  unnecessary  or  inefficient.  The  circular  gypsum 
dressing  is  not  well  adapted  to  these  fractures,  though  the  moulded  gyp- 
sum splints  are  not  objectionable. 

Daily  examination  is  a  wise  precaution  for  the  first  w^eek,  since  exces- 
sive inflammatory  swelling  and  a  tendency  to  displacement  are  frequent 
accompaniments  of  these  injuries.  The  splints  may  be  removed  in  four 
weeks.  Extreme  overriding  may  require  the  adjustment  of  continued 
extension.  In  cases  kept  in  bed  this  may  be  eflfected  by  a  weight  and 
pulley  ;  in  walking  cases  by  elastic  bands  attached  to  a  splint  prolonged 
beyond  the  hand.  Shortening  is  not  a  matter  of  much  moment  except 
when  due  to  such  overriding  as  may  impair  rotary  motion  by  encroaching 
upon  the  interosseous  space. 


Fig.  217. 


Scott's  splint  for  extension  in  fracture  of  forearm.     (Stimson.) 

Fracture  of  Shaft  of  Ulna. — If  the  radius  is  neither  broken  nor 
dislocated,  shortening  is  not  possible  in  fracture  of  the  ulnar  shaft. 
Lateral  or  angular  displacement  is  readily  discovered  because  of  the  sub- 
cutaneous position  of  the  ulna.  Alternating  pressure  above  and  below 
the  supposed  fracture,  or  grasping  the  two  portions  of  bone  firmly  with 
the  fingers  and  endeavoring  to  move  them  in  opposite  directions  will 
usually  prove  or  disprove  the  existence  of  crepitus  and  mobility.  If  the 
tip  of  the  olecranon  be  quickly  tapped  with  the  fingers  of  one  hand  while 
the  lower  end  of  the  normal  ulna  is  grasped  with  the  fingers  of  the  other 
hand,  the  transmission  of  the  vibration  along  the  entire  length  of  the 
bone  will  be  readily  felt.  In  a  broken  bone  this  transmission  will  be 
much  less  perfect.  Attempts  to  twist  the  arm  may  develop  crepitus 
otherwise  not  easily  elicited.  Forward  dislocation  of  the  head  of  the 
radius  is  said  to  be  a  not  unusual  complication  of  ulnar  fractures,  and 
may  be  overlooked. 

_  Moulding  by  digital  pressure  is  the  only  efficient  agent  for  correcting 
displacement,  and  must  be  so  exerted  as  to  avert  infringement  of  the 
interosseous  space  by  angular  deviation  of  the  fragments.  The  same 
dressing  as  that  described  for  fracture  of  the  shafts  of  both  bones  is  appli- 
cable, though  complete  supination  is  not  demanded  as  in  the  former  case. 
The  prone  position  is  not  allowable,  but  the  semi-supine  will  often  do  as 
well  as  the  supine.  In  most  cases  the  elbow  joint  had  better  be  controlled. 
The  circular  gypsum  dressing  is  often  very  convenient  and  efficient.     If 


40G 


DISEASES    AND    INJURIES    OF    BONES. 


the  posterior  gutter  of  felt  or  metal  is  us^ed,  it  is  inipurtant  that  it  should 
support  the  ulna  along  its  entire  shaft  as  well  as  at  its  ends,  lest  sagging 
occur  at  the  seat  of  fracture.  Tlie  splints  should  be  kej)t  on  about  three 
weeks. 

Fractures  of  the  Shaft  of  the  Radius. — The  function  of  the  radius 
as  the  movable  segment  of  the  forearm,  to  which  the  hand  is  attached, 
gives  great  importance  to  this  fracture  and  warrants  a  guarded  prognosis. 
Displacement  is  liable  to  be  angular,  forward  and  toward  the  ulna,  and 
the  supinating  muscles  have  a  tendency  to  supinate  fully 
Fig.  218.  the  upper  fragment  if  the  solution  of  continuity  occurs 

above  the  round  pronator's  insertion  ;  while  the  hand 
and  lower  fragment  tend  to  take  the  prone  position. 
Marked  displacement  of  the  lower  fragment  at  its  upper 
end  toward  the  ulna  alters  the  plane  of  the  lower  articular 
face  of  the  bone  and  gives  the  hand  an  abnormal  devia- 
tion toward  the  radial  side.  Power  of  voluntary  supina- 
tion and  pronation  is  gone,  and  the  hand  and  foi'earm 
when  grasped  seem  to  be  loose  and  flaccid.  Overlap- 
ping is  impossible  unless  the  splint-like  ulna  be  broken 
or  dislocated. 

The  diagnosis  is  established  by  mobility,  crepitus,  and 
occurrence  of  the  deformities  just  mentioned.     Absence 
of  rotation  of  the  radial  head  when  the  hand  is  grasped 
and  twisted  backward  and  forward  is  a  certain  indication 
of  fracture.     In  making  this  examination  the  surgeon 
should  grasp  the  elbow  and  place  his  thumb  on  the  head 
of  the  radius  as  it  lies  just  below  the  outer  condyle  of  the 
humerus.     A  rubbing  sensation  similar  to  fracture-crepi- 
tus  is  here  quite  often  developed  when  no  fracture  exists. 
This  is  due  to  friction  of  the  joint  surfaces  or  to  inflam- 
matory exudation  among  the  muscles  and  tendons.     The 
Fracture  of  shaft     treatment    should    be  the    same  as  in  fracture  of  both 
of  radius.  (IIamil-     bones,  with  the  limb  kept  in  the  supine  posture.     This  is 
TON.)  especially  demanded  in  fractures  of  the  upper  part  of 

the  shaft.  If  the  hand  is  much  displaced  extension  of 
the  ulnar  side  may  be  valuable  in  obtaining  and  maintaining  correct 
apposition.  In  accompanying  dislocation  of  the  lower  end  of  the  ulna 
extension  by  some  such  device  as  that  figured  under  fracture  of  both  bones 
may  be  necessary.  ]\Iotion  of  the  hand  and  elbow  had  better  be  controlled 
in  most  cases.  At  the  end  of  three  weeks  the  splints  may  be  discontinued 
and  a  simple  bandage  used. 


Fractures  near  the  Wrist-joint, 

Fractttre  of  the  Lower  End  of  the  Radius. — This  exceedingly 
common  fracture  was  long  misunderstood  and  is  still  very  often  improperly 
treated.  It  is  frequently  designated  by  the  name  of  one  or  other  of  those 
writei-s  who  have  discussed  it,  but  I  shall  not  mention  the  names,  since 
such  nomenclature  serves  to  confuse  the  student  and  to  perpetuate  erro- 
neous teaching.  The  usual  fracture  line  is  situated  from  one-third  to 
three-quarters  of  an  inch  above  the  articular  surface  of  the  bone ;  and  is 
generally  more  or  less  transverse  in  direction,  though  some  tendency  to 
lateral  or  antero-posterior  obliquity  is  not  infrequent. 


FRACTUEES    NEAE    THE    WKIST    JOINT. 


4or 


Displacement  of  the  lower  fragment  backward  upon  the  lower  end  of 
the  upper  fragment  is  the  ordinary  deformity  and  is  due  to  the  fracturing 
force,  not  to  muscular  contraction.  Some  impaction  is  quite  frequent 
from  driving  of  the  dorsal  wall  of  the  upper  into  the  cancellated  struc- 


Vertical  section  showing  epiphyseal  sepai-atiou  and  backward  displacement  of  lower 
end  of  radius.     (Brtaxt.) 

ture  of  the  lower  fragment ;  and  actual  loss  of  substance  from  crushing 
the  bony  tissue  is  not  unusual.  At  times  there  is  little  displacement ;  at 
others  it  occurs  at  the  radial  but  not  at  the  ulnar  side  of  the  lower  frag- 
ment, which  is  tilted  obliquely  backward.     The  styloid  process  of  the 

Fig.  220. 


Deformity  in  fracture  of  lower  end  of  radius  (diagrammatic).     (Levis.) 

radius  is  carried  upward  and  backward  by  this  displacement ;  and,  there- 
fore, in  fracture  of  the  lower  end  of  the  radius  the  radial  styloid  process 
is  often  on  the  same  level  as,  or  even  higher  than,  the  ulnar  styloid 
process. 

FiCx.  221. 


Diagram  of  displacement  in  fracture  of  lower  end  oi  radius.     (Levis.) 

This  angular  displacement  tends  to  throw  the  articular  surface  with  the 
attached  carpus  upward,  backward,  and  to  the  radial  side.  Hence  occur 
the  peculiar  deviation  of  the  hand  and  the  under  prominence  of  the  lower 
end  of  the  ulna,  which  gives  such  a  characteristic  appearance  to  the  limb 


408 


DISEASES    AND    INJURIES    OF    BONES. 


after  this  injiirv.  The  hand  is,  as  it  were,  carried  away  from  the  ulna  by 
the  force  whicli  breaks  the  radius  and  displaces  the  lower  fragment. 
Sometimes  the  ulna  is  actually  forced  throujjh  the  integument  by  the  vio- 
lence with  which  the  hand  is  forced  away  from  it,  on  account  of  the  forc- 
ible shortening  of  the  radius.  Such  a  wound,  however,  does  not  necessarily 
create  an  open  or  compound  fracture,  for  the  wound  does  not  always  com- 
municate with  the  fracture.  Prepared  specimens  of  united  fractures  give 
perhaps  a  false  notion  of  the  amount  of  impaction  originally  existing, 
because  the  formation  of  callus  beneatli  the  stripped-up  j)eriosteum  or 
the  dorsal  surface  is  n)isleading. 

Fig.  222. 


•'^^i^^'- 


An  old  fracture  of  lower  end  of  radius  united  with  deformity  uncorrected.    (Erichskn.) 


The  wrist-joint  is  not  involved  unless,  as  often  happens,  longitudinal 
lines  of  comminution  divide  the  lower  fragment  or  base  of  the  bone  into 
more  than  one  piece.  Fracture  of  the  lower  end  of  the  ulna,  or  of  its 
styloid  process  alone,  and  rupture  of  the  radio-ulnar  ligaments  and  carti- 
laginous attachments  are  occasional  associated  lesions;  but,  as  a  rule, 
fracture  of  the  base  of  the  radius  is  uncomplicated  except  by  commi- 
nution. 

In  young  persons  epiphyseal  separation,  with  a  causation  and  deformity 
similar  to  that  which  pertains  to  fracture,  may  occur.  The  treatment  of 
the  two  injuries  is  identical. 

Fio.  22.3. 


Vertical  section  of  fracture  of  lower  end  of  radius,  showing  usual  backward 
displacement.     (R.  W.  S.«ith.) 

The  fracture  just  described  is  practically  the  only  one  that  occurs  at 
the  lower  extremity  of  the  radius;  though  in  rare  cases  irregular  fracture 
lines  splitting  off  the  radial  or  ulnar  side  of  the  base  by  lines  more  or 
less  vertical  running  into  the  joint  have  been  described.  Displacement 
forward  of  the  lower  fragment,  that  is,  displacement  toward  the  palmar 
surface,  has  been  described  as  occurring  after  transverse  fracture  above 
the  joint  when  the  force  has  been  received  upon  the  back  instead  of,  as 
usually,  upon  the  palm  of  the  hand. 

The  uniformity  of  the  lesion  produced  when  the  radius  is  broken  at  the 
wrist  shows  that  the  mechanical  conditions  causing  the  fracture  are  usuallv 


FRACTURES    NEAR    THE    ^VRIST    JOINT.  409 

the  same.  When  a  mau  falls  either  forward  or  backward  his  arms  are  ex- 
tended to  protect  himself,  and  the  violence  consequently  is  received  on  the 
palms  of  the  outstretched  but  not  completely  pronated  hands.  The  force 
is  thence  transmitted  to  the  radius  which  is  concave  on  its  palmar  surface. 
Fracture  occurs  across  this  concave  portion  of  the  bone:  1.  Because  the 
arch  has  strain  brought  upon  it,  and  is  by  nature  a  weak  part  of  the  bone. 
2.  Because  there  is  a  cross-breaking  force  exerted  here,  when  the  hand  is 
violently  extended  backward,  by  the  ligaments  on  the  palmar  aspect  of 
the  joint;  the  end  of  the  bone  is  thus  torn  off.  3.  Because  penetration 
and  crushing  of  the  cancellated  osseous  tissue  is  caused  by  the  lower  end 
of  the  bone  being  driven  against  the  shaft. 

Stimson  thinks  that  the  first  theory  is  a  better  explanation  of  the  usual 
mechanism  of  the  fracture  than  the  others,  though  he  admits  that  the 
lesion  may  be  caused  in  all  three  ways.  I  am  inclined  to  believe  in  the 
truth  of  his  argument. 

The  symptoms  of  the  fracture  are  so  marked  that,  in  a  typical  case, 
error  in  diagnosis  is  impossible,  if  it  is  only  recollected  that  dislocation  of 
the  radio-carpal  joint  is  exceedingly  rare.  The  deformity  of  the  fracture 
so  resembles  that  of  backward  dislocation  of  the  carpus  that  the  fracture 
has  at  times  been  called  a  dislocation.  This  error  has  received  apparent 
confirmation  from  the  fact  that  after  the  displaced  lower  fragment  is 
pushed  into  position,  there  is  little  tendency  except  in  comminuted 
fractures,  to  reproduction  of  the  deformity.  The  transverse  character  of 
the  break,  and  the  absence  of  muscular  displacing  causes  render  secondary 
displacement  almost  impossible  unless  the  wrist  is  subjected  to  consider- 
able violence.  Let  the  student  recollect  that  injuries  of  the  wrist  sug- 
gesting dislocation  of  the  carpus  are  nearly  always  fractures  of  the  lower 
extremity  of  the  radius. 

Symptoms. — -The  characteristic  distortion  has  given  the  name  "silver 
fork  fracture "  to  the  injury.  The  hand  is  apt  to  be  held  semi-prone. 
Voluntary  movements  of  the  wrist  are  painful,  and  hence  are  lost, 
though  finger  motions  are  but  slightly  impaired.  On  the  radial  side  of 
the  back  of  the  wrist  there  is  a  prominence,  the  upper  margin  of  which 
can  sometimes  be  felt  as  a  sharp  bony  edge.  The  radial  extensor  tendons 
may  sometimes  be  felt  stretched  across  the  space  between  the  shaft  and 
the  upper  portion  of  this  prominence,  which  is,  of  course,  the  displaced 
lower  fragment.  Forced  flexion  of  the  hand  will  render  these  tendons 
more  tense  and  therefore  more  easily  perceived.  On  the  palmar  surface 
of  the  wrist  there  is  a  transverse  furrow  behind  the  ball  of  the  thumb, 
and  behind  that  a  prominence  due  to  the  lower  end  of  the  upper  fragment 
and  the  inflammatory  effusion  which  takes  place  into  the  sheaths  and 
tendons  of  the  flexor  mass  of  muscles.  The  hand  usually  deviates  some- 
what to  the  radial  side,  the  ulna  is  unduly  prominent  on  the  posterior  and 
ulnar  aspect  of  the  wrist,  and  the  styloid  process  of  the  radius  is  on  a 
level  or  even  higher  than  that  of  the  ulna.  Mobility  and  crepitus  are 
often  absent  because  of  impaction ;  though  both  may  be  developed  by 
strong  pressure  upon  the  dorsal  prominence,  which  at  the  same  time 
forces  the  displaced  portion  of  the  radius  into  position  with  a  sensation  ot 
snapping  or  grating.  In  comminuted  or  unimpacted  cases  motion  and 
crepitus  are  often  easily  detected.  Motion  at  the  wrist-joint  or  in  the 
carpal  articulations  may  be  mistaken  for  fracture  mobility.  When  no 
displacement  occurs  thei-e  may  be  no  distinctive  symptoms  except  a  tender 
spot  upon  the  bone,  which  cannot  be  attributed  to  arthritis  as  it  is  a  little 
above  the  known  location  of  the  joint. 


410  laSEASES    AND    INJURIES    OF    BONES. 

Diagnosis. — The  diagnosis  must  be  made  between  sprain  of  the  wrist, 
fracture  of  the  lower  end  of  the  radius,  and  dislocation  of  the  carpus.  If 
no  deformity  such  as  described  above  exists,  it  nevertheless  may  be  a 
fracture  with  little  laceration  of  the  periosteum  and  no  appreciable  dis- 
placement. The  diagnosis  then  hangs  upon  the  character  of  the  vul- 
nerating  force,  the  age  of  the  patient,  and  the  position  of  the  tenderness 
on  pressure.  If  the  patient  is  beyond  middle  age,  has  fallen  heavily  on 
his  palm  and  comjilains  of  localized  tenderness  about  half  an  inch  above  the 
joint,  fracture  is  the  probable  lesion.  If  the  point  of  tenderness  is  over 
the  w-rist-joint,  if  the  patient  is  young,  or  if  the  fall  was  a  slight  one,  a 
sprain  with  subsequent  arthritis  is  the  most  likely  injury.  When  the 
usual  displacement  backward  of  the  lower  fragment  has  taken  ])lace,  an 
error  is  impossible  after  a  careful  examination,  though  it  is  true  that  the 
swelling  of  severe  sprain  does  sometimes  simulate  the  deformity  of 
fracture. 

Backward  dislocation  of  the  carpus  is  the  only  luxation  resembling 
fracture,  and  any  dislocation  about  the  wrist  is  exceeding  rare.  Backward 
dislocation  would  show  no  change  in  the  relative  position  of  the  styloid 
processes  to  each  other,  would  give  a  smooth,  laterally  convex  ui)per 
border  to  the  dorsal  prominence,  and  would  be  reduced  with  a  smooth 
snap  rather  than  with  a  rough  grating.  Deformity  would  probably  be 
more  easily  reproduced  than  in  the  usual  n(m-comminuted  fracture.  Dis- 
location of  the  radio-ulnar  joint  would  give  a  very  different  distortion 
from  that  of  fracture  of  the  base  of  the  radius. 

In  a  person  of  fifteen  to  twenty  years,  epiphyseal  separation  is  to  be 
expected  rather  than  fracture.  The  exact  diagnosis  is,  however,  unim- 
portant, for  the  treatment  is  identical  with  that  of  fracture.  Inter- 
ference with  the  future  growth  of  the  bone  may  perhaps  follow  epiphyseal 
separation. 

Treatment. — The  essential  point  in  the  treatment  of  this  fracture  is 
early  and  complete  replacement  of  the  lower  fragment.  The  protracted 
convalescence  and  frecjuent  stiffness  of  the  wrist  and  fingers  seen  afler 
this  injury  are  due  to  imperfect  reduction  of  the  fracture  and  the  confine- 
ment of  the  fingers  during  the  use  of  the  fracture  dressing.  When  there 
is  neither  comminution  nor  loss  of  tissue  by  crushing,  the  fracture  can 
usually  be  cured  in  three  to  five  weeks  with  little  or  no  deformity,  and 
without  stiffness  of  the  fingers.  When  comminution  and  crushing  exist, 
cure  without  impairment  of  motion,  though  perhaps  with  more  or  less 
persistent  deformity,  is  nearly  always  possible,  and  in  the  same  time. 
When  I  say  "  cui-ed,"  I  do  not  mean  that  every  vestige  of  swelling  and  of 
osseous  thickening  disappears  so  soon,  but  that  the  limb  is  capable  of  per- 
forming its  ordinary  functions.  Old  and  rheumatic  patients  may  perhaps 
exhibit  a  greater  tendency  than  others  to  rigidity  of  the  joints  ;  but  I 
cannot  insist  too  strongly  on  my  belief  that  stiff  fingers  are  usually  an 
indication  of  imperfect  reduction  of  the  fragments,  which  by  their  pro- 
jection interfere  with  the  extensor  and  flexor  tendons  and  cause  adhesive 
inflammation.  No  apparatus  shoukl  be  applied  that  restricts,  at  any 
period  of  the  treatment,  full  and  free  motion  of  the  fingers.  In  uncompli- 
cated cases  the  splint  need  not  be  worn  more  than  about  ten  days ;  pro- 
vided that  the  patient  is  sufficiently  intelligent  to  avoid  submitting  the 
arm  to  unexpected  strains  and  blows.  This  is  because  of  the  slight 
tendency  to  reproduction  of  deformity  in  the  properly  reduced  fracture. 
In  careless  patients,  and  in  comminuted  or  otherwise  complicated  fracture, 
support  by  the  splint  should  be  continued  for  three  weeks.     Uncompli- 


FEACTURES    NEAR    THE    WRIST    JOINT  411 

cated  cases  in  intelligent  persons  may  be  treated  without  any  splint 
whatever.  A  band  of  adhesive  plaster,  or  a  roller  bandage  applied 
firmly  around  the  wrist  at  the  seat  of  injury,  is  all  that  is  necessary  after 
perfect  reduction  has  been  accomplished.  Passive  motion  is  probably 
never  necessary  if  the  fracture  is  properly  replaced,  and  the  play  of  the 
lingers  not  restricted  during  the  use  of  the  splint. 

Keduction  is  always  painful,  but  is  usually  so  quickly  accomplished 
that  an  ansesthetic  is  seldom  needed.  Ether  or  nitrous  oxide  should  be 
employed,  however,  if  there  is  likelihood  of  the  pain  preventing  perfect 
coaptation  of  the  parts.  The  surgeon  must  apply  force  directly  to  the  frag- 
ments. Let  him  put  the  patient's  hand  in  the  prone  position,  grasp  the 
middle  of  the  forearm  with  one  hand,  and  take  hold  of  the  patient's  palm 
with  the  other  hand  in  such  a  manner  that  his  thumb  can  make  strong 
pressure  upon  the  apex  of  the  dorsal  prominence.  By  making  traction 
on  the  hand  of  the  patient  and  then  suddenly  flexing  the  patient's  wrist, 
while  at  .the  same  time  he  presses  with  his  thumb  strongly  upon  the  pro- 
jection at  the  back  of  the  wrist,  he  can  nearly  always  force  the  lower 
fragment  into  its  proper  position  without  difficulty.  A  repetition  of  this 
manoeuvre  is  sometimes  requisite  before  accurate  replacement  is  obtained. 
The  grating  produced  as  the  fragment,  which  may  have  been  impacted, 
is  driven  into  its  normal  position,  can  at  times  be  distinctly  heard  by 
bystanders.  The  limb  at  once  assumes  its  normal  contour.  The  disap- 
pearance of  the  bony  edge  or  shoulder  previously  perceptible  to  the  touch 
where  the  upper  margin  of  the  lower  fragment  was  elevated  above  the 
level  of  the  shaft  of  the  radius,  is  an  indication  that  reduction  of  the 
backward  displacement  has  been  accomplished.  Still  further  manipula- 
tion may  occasionally  be  necessary  to  reconstruct  the  normal  outline  of 
the  radius,  which  has  at  the  wrist,  it  will  be  remembered,  a  concave 
palmar  surface. 

If  great  comminution  or  crushing  has  been  incidental  to  the  fracture, 
perfect  restoration  of  shape  may  be  impossible,  although  the  deformity  can 
be  greatly  diminished.  In  such  cases,  also,  retention  of  the  fragments  in 
good  position  may  be  somewhat  difficult.  Firm  impaction  or  entangle- 
ment of  the  fragments  in  the  tendons  or  dorsal  periosteal  bands  may 
require  that  the  hand  and  attached  lower  fragment  be  first  bent  strongly 
backward,  in  order  to  release  the  interlocking  before  making  traction, 
flexion,  and  pressure.  This  preliminary  measure  is  not  often  necessary. 
After  reduction  has  been  accomplished  any  form  of  dressing  is  allowable 
provided  it  immobilizes  the  limb,  does  not  tend  to  obliterate  the  normal 
curve  of  the  palmar  face  of  the  radius,  and  permits  the  patient  to  move 
his  fingers.  It  was  formerly  thought  that  splints  deflecting  the  hand  to 
the  ulnar  side  exerted  traction  on  the  radial  side  of  the  wrist,  and  were 
therefore  indicated.  This  is  incorrect  teaching.  Such  splints  are  unneces- 
sary, as  the  deflection,  only  causes  the  carpus  to  roll  in  the  articular  sur- 
face of  the  radius.  The  hand  should  be  placed  in  the  prone  or  semi-prone 
position,  and  a  single  splint,  extending  from  below  the  elbow-joint  to  the 
middle  of  the  metacarpus,  applied  either  to  the  dorsal  or  palmar  aspect  of 
the  forearm.  It  is  essential  that  the  palmar  splint,  if  it  be  chosen,  should 
be  convex  on  its  upper  surface  at  its  carpal  extremity,  so  as  to  preserve 
the  integrity  of  the  radial  concavity  and  not  to  make  the  palmar  surface 
of  the  radius  flat,  by  forcing  upward  the  lower  fragment  which  has  just 
been  pushed  down  into  proper  position  by  the  surgeon's  manipulations. 
This  convexity  may  be  obtained  by  using  the  moulded  splint  of  Levis, 
or  a  splint  of  wood  with  a  hard  convex  pad  to  fit  into  the  palmar  concavity 


412 


DISEASES    AND    INJURIES    OF    BONES. 


of  the  radius.  It  should  be  seen  that  the  pad  properly  fits.  The  surgeon 
can  readily  make  a  pad  out  of  soft  wood  and  fasten  it  with  screws  to 
a  straight  splint.     No  dorsal  splint  is  needed  with  either  of  these  splints. 


Fk;.  224. 


Normal  ceutre  of  llon'^ 


Lower  fragment  puitlieil  by  splint. 


Spliut. 
Showing  injurious  effect  of  straight  palmar  splint  in  fracture  of  lower  end  of  radius. 

If  it  is  inconvenient  to  obtain  a  proper  form  of  curved  palmar  splint 
a  flat  splint  may  be  applied  to  the  dorsal  surface  of  the  radius,  which 
presents  no  curve  but  is  straight.  Bond's  splint,  so  fre<juently  employed, 
is  dangerous  to  the  future  contour  and  utility  of  the  limb,  and  should 
never  be  used.  After  the  splint  has  been  employed  for  from  a  week  to 
ten  days,  varying,  as  above  stated,  with  the  kind  of  fracture  and  disposi- 
tion of  the  patient,  it  is  well  to  substitute  it  by  a  strip  of  adhesive  plaster, 
two  inches  wide,  applied  circularly  around  the  wrist  so  as  to  give  moderate 
support  to  the  partially  consolidated  fracture. 


Levis's  metal  radius  splint. 

If  union  has  already  occurred  in  a  fracture  treated  without  proper 
reduction  the  surgeon  should  attempt  refracture  and  adjustment  even 
after  the  lapse  of  several  months,  provided  that  the  fingers  were  very 
rigid  or  the  deformity  very  great.  It  is  not  likely  that  as  much  can  he 
accomplished  in  such  cases  as  was  possible  immediately  after  the  receipt 
of  injury,  but  proper  reduction  should  be  undertaken  even  at  late  periods. 


FRACTURES  OF  THE  METACARPUS.         413 

Good  use  of  the  hand  is  often  obtained  finally  even  where  there  exists  a 
considerable  degree  of  deformity.  Rigidity  of  the  fingers  if  permitted  to 
occur  remains,  however,  for  many  months.  Refracture  for  correction  of 
deformity  is  readily  accomplished  if  the  surgeon  will  bend  the  bone 
across  his  knee.     Osteotomy  need  not  be  undertaken. 

Other  Fractures  near  the  Wrist- joint. — Fracture  of  the  styloid 
process  of  either  the  ulna  or  radius  occurs,  though  rarely.  The  diagnosis 
is  not  diflicult.  All  that  is  needed  for  treatment  is  such  a  dorsal  or 
palmar  splint  as  will  prevent  motion  at  the  wrist  and  fix  the  hand  in  a 
deflected  position  ;  toward  the  ulnar  side  in  fracture  of  the  ulnar  styloid 
process,  toward  the  radial  side  in  fracture  of  the  styloid  process  of  the 
radius.  A  circular  gypsum  dressing  will  probably  best  meet  the  indica- 
tions. Fracture  of  the  lower  end  of  the  radius,  with  displacement  for- 
ward— that  is,  toward  the  palmar  surface  has  been  mentioned  as  a  rare 
form  of  injury,  due  to  receipt  of  violence  on  the  back  of  the  hand.  It 
should  be  treated  with  the  same  form  of  splints  as  is  the  common  fracture 
at  the  lower  end  of  the  bone;  but  of  course  the  jDrimary  reduction  is  to 
be  made  by  pressure  in  an  opposite  direction. 

Fracture  of  both  the  radius  and  ulna  just  above  the  joint  occasionally 
happens.  It,  in  appearance,  much  resembles  backward  luxation  of  the 
carpus,  but  is  distinguished  therefrom  by  crepitus,  mobility  and  the 
preservation  of  the  normal  relation  of  the  styloid  processes  to  the  bony 
landmarks  of  the  hand.  The  treatment  is  similar  to  that  of  fracture  of 
the  lower  end  of  the  radius,  but  this  injury  must  not  be  treated  without 
a  splint,  as  some  forms  of  the  latter  injury  may  be.  In  instances,  how- 
ever, where  the  line  of  fracture  is  some  distance  above  the  joint,  the  lesion 
partakes  of  the  characteristics  of  fracture  of  the  shafts  of  the  two  bones 
and  should  be  treated  as  such,  in  order  to  preclude  the  possibility  of 
callus  interfering  with  future  supination  and  pronation. 


Fractures  of  the  Carpus,  Metacarpus,  and  Phalanges. 

Fractures  of  the  Carpus. — Uncomplicated  fractures  of  the  carpal 
bones  are  rare,  though  it  is  probable  that  they  occur  at  times  in  connec- 
tion with  radial  fractures  and  other  injuries,  but  are  unrecognized.  The 
diagnosis  must  be  made  by  the  presence  of  crepitus  or  deformity.  Pre- 
ternatural mobility,  unless  very  marked,  could  be  determined  only  with 
difiiculty  in  a  region  containing  so  many  movable  bony  components. 
Ankylosis  of  some  of  the  intracarpal  articulations  seems  a  probable  con- 
sequence of  carpal  fractures,  but  it  would  cause  little  disability.  Crush- 
ing injuries,  due  to  direct  violence,  and  causing  extensive  lesions  of  the 
soft  parts,  quite  often  produce  open  and  comminuted  carpal  fractures. 
Such  cases,  however,  do  not  derive  their  importance  from  the  broken 
carpal  bones. 

Fractures  of  the  Metacarpus. — The  so-called  metacarpal  bone  of 
the  thumb  is  not  included  in  this  discussion  because  it  is  anatomically  a 
phalanx.  Its  fractures  are  included,  therefore,  under  fractures  of  the 
phalanges.  Metacarpal  fractures  are  generally  caused  by  direct  violence 
received  on  the  dorsal  or  palmar  aspect  of  the  hand  ;  or  by  force  so  applied 
to  the  anterior  extremity  of  one  of  the  bones  as  to  exaggerate  its  normal 
curve.  To  the  latter  mechanism  is  due  the  occasional  breaking  of  a 
metacarpal  bone  when  a  man  strikes  a  violent  blow  with  his  fist,  receiv- 
ing, of  course,  the  impact  on  his  knuckles.     The  common  displacement  is 


414  DISEASES    AND    INJURIES    OF    BONES. 

anirular  with  the  projection  of  the  angle  toward  the  back  of  the  hand 
and  the  auterior  end,  or  head,  of  the  bone  prominent  in  the  palm.  Lateral 
overridinir  is  not  an  unusual  feature.  The  single  epiphysis  of  the  bone 
which  is  at  the  anterior  extremity,  may  be  torn  oti'  in  patients  not  over 
twenty  years  of  age,  and  give  the  symptoms  of  true  fracture. 

When  firm  pressure  is  made  in  the  palm,  pain,  yielding,  and  the  occur- 
rence of  a  prominence  on  the  back  of  the  hand  will,  as  a  rule,  be  de- 
veloped in  those  eases  of  metacarpal  fracture  that  are  not  at  once  clearly 
demonstrated  by  the  ordinary  symptoms.  A  sharp  [)ain  at  the  seat  of 
fracture  can  often  be  produced  by  taking  hold  of  the  finger,  attached  to 
the  metacarpal  bone  supposed  to  be  injured,  and  suddenly  pushing  it 
toward  the  wrist.  Actual  shortening  of  the  broken  bone  is  often  (piite  as 
characteristic  as  motion  and  crepitus.  Union  takes  place  in  about  three 
weeks. 

Traction  of  the  finger  and  pressure  upon  the  dorsal  prominence  are 
sufficient  to  overcome  the  displacement  in  the  majority  of  cases.  If  no 
tendency  to  recurrence  of  deformity  exists,  a  layer  of  cotton  iu  the  palm 
and  another  on  the  back  of  the  hand,  held  in  position  by  a  circular 
bandage,  constitute  an  efficient  retentive  apparatus,  though  care  must  be 
observed  lest  lateral  displacement  be  caused  by  the  bandage.  In  other 
cases  support  to  the  fragments  and  the  adjoining  bones,  and  prevention  of 
deformitvis  best  obtained  by  placing  a  cylinder  of  wood,  a  roller  bandage, 
or  a  spherical  object,  such  as  a  billiard  ball,  in  the  palm,  and  keeping  the 
flexed  fingers  closed  upon  it  by  strips  of  adhesive  ])laster  carried  from 
the  back  of  the  wrist,  over  the  knuckles,  around  to  the  palmar  surface  of 
the  wrist. 

Longitudinal  splints  applied  to  the  palm  or  dorsum,  or  both,  and  con- 
trolling the  wrist  and  fingers,  may  be  preferable  in  some  cases.  In  other 
instances  short  transverse  splints  placed  across  the  back  and  front  of  the 
hand  may  be  found  more  efficient  in  meeting  the  indications.  When  the 
tendeucv  to  overlapping  is  marked,  no  method  is  as  good  as  continuous 
extension.  This  can  be  done  by  the  use  of  adhesive  plaster  strips  apj)lied 
to  the  back  and  front  of  the  finger,  and  a  rubber  cord  extending  from  the 
loop  of  plaster  to  a  nail  or  screw  in  the  end  of  a  long  palmar  splint  firmly 
adjusted  to  the  forearm  and  hand  and  extending  beyond  the  finger-tips. 
This  method  is  identical  with  that  used  in  fractures  of  the  thigh-bone. 

Fr.\ctukes  of  the  Phalanges. — As  these  injuries  are  generally 
caused  by  direct  violence,  they  are  fre([uently  complicated  by  comminu- 
tion, dislocation,  and  great  laceration  of  the  soft  parts.  The  phalanges 
and  the  so-called  metacarpal  bone  of  the  thumb,  which,  properly  con- 
sidered, is  a  phalanx,  are  developed  from  two  ossific  centres ;  one  for  the 
shaft  and  one  for  the  posterior  extremity,  or  base.  Epiphyseal  fracture 
is,  therefore,  a  possible  lesion  iu  persons  not  over  twenty  years  of  age. 
The  swelling  after  phalangeal  fracture  often  conceals  the  deformity  to 
such  an  extent  that  mobility  and  crepitus  are  the  chief  diagnostic  features. 
The  prognosis  is  good  except  when  great  comminution  or  the  occurrence 
of  suppuration  renders  necrosis  probable.  Quite  firm  union  may  be  ex- 
pected in  about  two  weeks  if  the  fracture  is  uncomplicated. 

Lateral  and  rotary  deviation  is  to  be  corrected  w-ith  especial  care  in 
phalangeal  fractures,  for  a  crooked  finger  is  not  only  unsightly,  but  may 
interfere  with  the  manual  dexterity  of  an  artisan.  Bowing  of  the  middle 
of  the  phalanx  toward  the  palm  tends  to  prevent  the  patient  grasping  ob- 
jects firmly  and  must  be  avoided.  If  ankylosis  is  apprehended  the  finger 
should  be  slightly  flexed  during  treatment,  for  stiffness  in  the  partially- 


FEACTURES    OF    THE    FEMUR. 


415 


bent  position  is  the  least  inconvenient  and  least  noticeable.  A  splint  of 
gutta  percha,  pasteboard,  felt,  copper,  or  zinc  moulded  to  the  palmar  sur- 
face of  the  member  and  to  the  finger-tip  is  a  neat  and  effective  fracture 
apparatus.  If  the  proximal  phalanx  is  the  seat  of  lesion,  such  a  splint 
should  include  the  palm  and  wrist.  A  cylindrical  pad  in  the  palm,  with 
the  fingers  closed  over  it,  and  kept  so  fixed  by  adhesive  plaster,  as  de- 
scribed under  fractures  of  the  metacarpus,  is  often  a  good  dressing.     A 

Fig.  22(5. 


Gutta  percha  splint  for  finger.     (Hamilton.) 

straight  palmar  splint,  the  circular  gypsum  dressing,  or  continued  exten- 
sion by  a  rubber  band  may,  in  certain  circumstances,  be  more  advanta- 
geous. If  necessary,  the  finger  or  fingers  adjoining  the  broken  one  may 
be  used  for  giving  lateral  support,  or  two  or  three  fingers  may  have  to 
be  kept  motionless  by  a  wide  splint  in  order  to  immobilize  the  injured 
member. 

Amputation  is  frequently  demanded  in  fractures  of  a  complicated 
character.  Conservatism,  however,  should  be  the  rule,  for  a  portion  of  a 
finger  or  a  stiff  one  is  often  better  than  none.  Especially  is  preserva- 
tion of  the  smallest  apology  for  a  thumb  desirable  in  order  that  the  patient 
may  have  something  to  oppose  to  the  other  fingers  when  grasping  objects. 
While  it  is  true  that  in  certain  mechanical  operations  a  deformed  or  im- 
movable finger  may  be  an  annoyance  and  disability,  and  while  recovery 
will  in  many  cases  be  sooner  attained  by  amputation  than  by  conserva- 
tive attemps ;  still  the  latter  course  is  to  be  advocated  in  doubtful  cases. 
Unexpectedly  good  results  are  often  secured,  even  when  joints  are  in- 
volved, and  the  patient  learns  to  manipulate  with  the  disabled  hand, 
which  moreover  preserves  its  complete  integrity.  The  risks  of  prolonged 
suppuration  and  of  other  secondary  troubles  which  may  follow  conserva- 
tism, are  practically  annihilated  by  antiseptic  methods.  After  cure  is 
complete  the  mechanic  can  test  the  utility  of  the  hand  for  a  few  months, 
and  then,  if  the  deformed  finger  is  a  detriment  to  bread-winning,  it  may 
be  removed  by  amputation  with  little  risk. 


Fractures  of  the  Femur. 

Fractures  at  the  Upper  End  of  the  Femur. — Of  these  there 
are  fractures  of  the  neck  which  may  involve  the  greater  trochanter  or 
head,  fractures  detaching  the  greater  trochanter,  and  fracture  through 
the  base  of  the  trochanter  and  upper  end  of  the  shaft.  The  first  variety 
is  common.  The  others  are  exceedingly  rare,  and  maybe  dismissed  with 
a  few  words  at  this  time. 


416 


DISEASES    AND    INJURIES    OF    BONES. 


Fracture  of  the  trochanter  is  the  result  of  direct  violence,  and  is  to  be 
diagnosticated  by  displacement  of  the  fragment,  character  of  the  injury, 
local  pain,  and  absence  of  the  symptoms  found  with  fracture  of  the  neck 
of  the  femur.  Epiphyseal  detachment  may  be  suspected  in  such  cases  if 
the  patient  is  not  over  eighteen  years  of  age.  A  bandage  or  strips  of  ad- 
hesive plaster  around  the  hips,  with  an  appropriate  compress,  would  seem 

Fi<;.  227. 


Aji/ietirs  at  i-'!';/ 
J"!ih<lftaio„t  fS'/'yCf^" 


Aitpenrs  nrciidDfl;/^ 


i ':;'i^    JoinsShiifi  iiiout  18"'  y.' 


Aip^peu  /'J-  lit  Q  ~mu. 


Joins  Shaft  iitZO' if. 


Posterior  surface  of  femur  showing  epiphyses.     The  tliree  upper  epiphyses  unite  about 
the  eighteeutli  year  ;  the  lower  one  about  the  twentieth  year.     (Gray.) 

to  be  the  proper  method  of  treatment.  Hooks  similar  to  those  employed 
for  fracture  of  the  patella  would  not  be  improper  if  the  displacement 
was  very  marked. 

Fracture  more  or  less  transverse  through  the  base  of  the  trochanter  and 
upper  part  of  the  shaft  is  said  to  occur.  Its  diagnosis  is  uncertain,  but 
its  treatment  is  the  same  as  for  fractures  of  the  neck. 

Fractures  of  the  femoral  neck  are  very  common  and  very  important 
surgical  lesions.  The  classification  of  Stimson  seems  to  be  the  best.  He 
divides  them  into  fractures  of  the  small  part  of  the  neck,  and  fractures 
at  the  base  of  the  neck.  The  former  is  identical  with  the  class  often 
called  intracapsular  fractures,  and  includes  the  rare  condition,  separa- 
tion of  the  epiphysis  of  the  head  ;  the  latter  includes  both  the  so-called 
extracapsular  fractures  and  those  which  are  partially  intracapsular.  The 
reasons  for  rejecting  the  old  classification  are :  that  the  neck  is  entirely 
covered  by  the  capsular  ligaments  in  front  and  below%  while  behind  and 


FRACTURES    OF    THE    FEMUR. 


417 


Fig.  228. 


above  only  about  three-fourths  of  its  length  is  so  covered,  and  that  the 
extent  of  capsular  envelopment  varies  in  different  persons ;  that  the 
synovial  membrane  does  not  extend  as  far  out  upon  the  neck  as  does  the 
the  capsule,  hence  a  part  of  the  neck  is  e.i-^ra-articular 
though  really  inira-capsular  ;  that  the  line  of  fracture 
is  frequently  not  confined  to  either  the  intra-  or  extra- 
capsular portion  of  bone,  and  that  the  clinical  diagnosis 
between  intra-  and  extra-capsular  lines  is  often  impos- 
sible ;  as  can  readily  be  understood  by  what  has  pre- 
ceded. Even  at  the  autopsy  the  fact  of  a  given  fracture 
being  intra-capsular,  or  rather  intra-articular,  for  it  is 
the  relation  to  the  joint  that  is  important,  can  only 
be  known  by  accurate  examination  of  the  synovial 
membrane.  This  is  further  complicated  by  the  fact 
that,  after  fracture,  the  outer  portion  of  the  cavity  of 
the  joint  may,  it  is  said,  be  obliterated  by  adhesion  of 
the  capsule  to  the  periosteum. 

Impaction  and  fixation  of  fragments  at  the  first 
receipt  of  injury  is  very  frequent  in  fractures  at  the 
base  of  the  neck,  and  not  infrequent  in  those  of  the 
small  part  of  the  neck.  Attempts  at  walking,  im- 
proper surgical  manipulation ,  and  other  secondary 
violence  often  cause  undesirable  separation  of  the  inter- 
locked fragments.  Cervical  fractures  of  the  femur  are 
often  due  to  slight  injuries,  as  a  twist  from  catching 
the  foot  in  a  fold  of  carpet,  missteps,  and  insignificant 
falls  on  the  knee,  buttocks,  and  side  of  thigh.  It  is 
possible  that  in  certain  positions  muscular  eflTorts  to 
avoid  falling  may  be  a  factor  in  causing  the  fracture. 
An  important  element  in  their  production  is  weakening  of  the  osseous 
tissue  by  senile  degeneration  which  begins  at  about  the  fiftieth  year  of 
life,  and  is  said  to  be  more  marked  in  women  than 
in  men.  This  degenerative  change  is  the  predis- 
posing cause  which  permits  slight  injuries  to  have 
such  a  disastrous  effect.  It  is  not  a  relative  in- 
ci'ease  of  earthy  constituents  that  renders  the  bone 
more  friable ;  but  an  actual  thinning  of  the  wall 
of  the  femur,  and  also  an  increase  in  size  of  the 
spaces  found  in  the  bone  for  vessels  and  fat.  The 
radiating  and  arched  lines  of  compact  bone  which 
cross  the  cancellous  portion  of  the  bone,  and 
which  are  so  readily  demonstrated  by  section  of 
the  upper  end  of  the  femur,  are  thus  absorbed. 
This  rarefaction  of  osseous  tissue,  and  consequent 
loss  of  resisting  power  to  strains,  is  a  much  more 
potent  factor  in  the  frequent  occurrence  of  frac- 
tures of  the  femoral  neck  than  the  change  of  angle  between  the  shaft 
and  neck  which  has  been  said  to  occur  with  advancing  age.  Fractures 
from  very  slight  kinds  of  violence  are  very  apt  to  be  at  the  small  part 
of  the  neck.  Fractures  of  the  small  part,  or  constriction  of  the  neck 
of  the  femur,  seldom  occur  before  the  age  of  fifty  years.  The  line,  which 
is  apt  to  be  nearly  transverse,  may  be  oblique  or  irregular,  and  even  run 
upward  into  the  head  of  the  bone.  Impaction,  with  fixation  of  frag- 
ments, and   comminution   are   not  unusual  features.     A  portion  of  the 

27 


Fracture  of  epi- 
physis of  great  tro- 
chanter and  frac- 
ture of  condyles. 
CAgnew.) 


Fig.  229. 


Fracture  of  epiphysis  of 
great  trochanter.  (Bry- 
ant.) 


418 


DISEASES    AND    INJURIES    OF    BONES. 


Fk;.  230. 


periosteum  may  remain  untorn,  and  assist  in  keej)ing  the  fragments  in 
juxtaposition.  In  other  cases  not  only  is  the  periosteum  completely  torn 
and  the  fragments  separated,  but  the  ca])sule  it.-^elf  rent  by  the  violence 

and  by  displacement  of  the  fragments. 
The  displacement  is  usually  of  the  shaft 
upward.  In  impacted  fractures  some 
degree  of  twisting  deformity  may  exist. 
The  shortening  of  the  limb  from  dis- 
placement is  apt  to  increase  gradually 
during  the  first  week,  but  rarely  exceeds 
one  inch,  except  when,  after  weeks  have 
elapsed,  absorption  of  the  neck  has  taken 
place. 

AVhen  these  fractures  are  repaired  it 
is  usually  accomplished  by  fibrous  tissue. 
Indeed,  it  has  been  asserted  that  bony 
union  never  occurs.  Such  statements 
are  erroneous,  though  it  is  true  that 
failure  of  union  or  fibrous  union  is  the 
most  common  result  of  the  reparative 
attempts.  Bony  union  does  occur,  though 
rarely.  The  question  is  of  little  clinical 
importance,  since  a  short  fibrous  bond 
gives  as  useful  a  limb  as  an  osseous  one; 
and  union  should  always  be  sought  by  treatment,  if  the  patient's  condiition 
will  permit  the  necessary  confinement. 

Examination  of  specimens,  with  or  without  a  history  of  fracture,  does 
not  throw  i\s  much  light  on  the  question  as  would  be  supposed,  because 
the  arthritic  changes  of  old  age  and  interstitial  absorption  of  the  neck  of 


Fracture  of  i..i:.  ...    ,jait  of  neck. 
(Hamilton.) 


Fifi.  2.31. 


Fig.  232. 


),J^ 


7  V 


^--^-*v 


Fracture  of  small  part  of  neck  united  by 
bone,  fibrous  tissue,  and  cartilage,  showing 
absorption  of  neck.    (Bryant.) 


Femur  of  opposite  side,  showing  amount 
of  bone  absorbed  on  injured  side. 
(Bryant.) 


the  femur  which  occur  subsequent  to  cervical  fractures,  obliterate  or 
simulate  lines  of  fracture.  Simple  contusion  of  the  hip  is  supposed  by 
some  writers  to  be  a  cause  sufficient  to  induce  in  the  aged  interstitial 
absorption  of  the  neck  of  the  femur. 


FRACTURES    OF    THE    FEMUR. 


419 


Fig.  233. 


Upper  fragment  driven 
into  the  trochanter  frag- 
ment.    (Geoss.) 


The  cause  of  such  frequent  defective  union  appears  to  be  want  of 
contact  between  the  fragments,  imperfect  immobilization,  and  some  consti- 
tutional peculiarity.  The  difficulty  of  obtaining  perfect  contact  and 
immobilization  when  the  small  upper  fragment  is  so  inaccessible  and  floats 
in  such  a  cup-like  cavity  as  the  acetabulum,  will 
be  easily  understood.  The  error  of  rude  manipu- 
lation, by  which  impacted  fragments  may  be  sep- 
arated, is  a  useful  lesson  taught  by  this  statement. 
It  would  seem  that  the  constitutional  tendency, 
already  mentioned  as  a  cause  of  the  extreme 
fragility  of  this  part  of  the  skeleton  in  aged  per- 
sons, would  tend  to  interfere  with  the  occurrence 
of  osseous  repair.  These  reasons  for  defective 
union  seem  to  be  sufficient  without  recourse  to 
those  often  given  :  namely,  deficient  blood  supply 
to  the  upper  fragment,  and  contact  of  the  frac- 
tured surfaces  with  the  synovial  fluid.  These 
agencies,  however,  possibly  exert  some  influence. 

The  symptoms  and  diagnosis  of  fractures  of  the 
small  part  of  the  neck  will  be  discussed  with  simi- 
lar topics  relative  to  fractures  at  the  base  of  the 
neck.  The  usual  result  after  fractures  of  the 
small  part  of  the  femoral  neck  is  disability  with 
eversion,  and  some  shortening  of  the  limb.  The 
patient  in  some  cases  can  walk  without  crutch  or  cane,  but  such  a  slight 
degree  of  lameness  is  uncommon.  Occasionally,  feebleness  from  pain, 
confinement,  and  age,  renders  the  unfortunate  patient  bedridden. 

In  fractures  at  the  base  of  the  neck  the  line  of  fracture  shows  a  ten- 
dency to  separate  the  neck  from  the  shaft  in  the  vicinity  of  the  inter- 
trochanteric line,  but  may  be  varied  or  complicated  by  lines  running 
downward  into  the  shaft,  splitting  off"  the  lesser  trochanter,  extending  along 
the  neck  toward  the  head,  or  involving  the  upper  portion  of  the  great 
trochanter.  Bending  the  neck  backward,  with  crushing  or  penetration 
near  the  posterior  part  of  the  greater  trochanter,  is  said  to  be  a  very 
common  form  of  the  injury.  Various  degrees  and  forms  of  penetration 
and  impaction  of  the  cervical  into  the  trochanteric  fragment  have  been 
described.  The  trochanteric  fragment  or  shaft  is  seldom  forced  into  the 
cancellated  structure  of  the  neck.  These  fractures  usually  unite  by  bone, 
and  in  six  or  seven  weeks  ;  showing,  therefore,  much  better  reparative 
effort  than  fractures  of  the  narrow  part  of  the  neck. 

Symptoms. — The  distinctive  symptoms  of  fracture  of  the  neck  of  the 
femur  are  motor  disability,  eversion,  shortening,  and  crepitation.  To  these 
may  be  added  certain  incidental  symptoms  that  occasionally  assist  in  the 
diagnosis. 

The  limb  is  usually  so  helpless  that  no  voluntary  effort  can  lift  it  from 
the  bed,  nor  can  the  weight  of  the  body  be  borne  upon  it  in  the  erect 
position.  Sometimes  slight  elevation  of  the  thigh  is  possible,  especially 
if  the  patient  can  get  a  purchase  on  the  bed  for  his  heel.  In  very  excep- 
tional cases  walking  on  the  injured  limb  has  been  possible.  Here  firm 
impaction  has  almost  certainly  existed.  In  making  a  differential  diagnosis 
the  helplessness  following  severe  sprain  or  contusion  must  not  be  for- 
gotten. 

The  posture  assumed  by  the  limb  is  almost  pathognomonic.  It  lies,  as 
the  patient  rests  on  his  back,  upon  its  outer  side  with  the  little  toe  almost 


420  DISEASES    AND    INJURIES    OF    BONES. 

or  (luite  touching  the  mattress,  and  the  lieel  on  a  level  with  the  space 
between  the  inner  malleolus  and  ])()int  of  the  calcaneuni  of  the  other  foot. 
A  slight  degree  of  flexion  and  abduction  at  the  hip  is  (juite  usual.  This 
eversion  is  probably,  in  the  main,  the  result  of  gravity  being  unresisted 
by  the  normal  j^upporting  agencies  of  the  limb  rather  than  due  to  the 
action  of  the  external  rotators  or  other  muscles.  In  some  cases  the  ever- 
sion is  slight,  at  other  times  the  toes  point  directly  upward,  while  in  rare 
instances  actual  inversion  exists.  Angular  deformity  at  the  seat  of  frac- 
ture, crushing,  impaction,  and  interlocking  of  iragments  and  entanglement 
in  capsular  rents  have  probably  an  agency  in  the  production  of  the  vary- 
ing degrees  of  eversion  and  inversion.  Eversion  is  the  usual  position  and 
is  very  suggestive  of  fracture,  though  it  has  been  observed  in  simple 
injuries  of  the  hip.  The  normal  position  of  the  limb,  indeed,  when  the 
recumbent  posture  on  the  back  is  assumed,  is  eversion,  and  especially  so 
when  the  knee  is  flexed  even  slightly.  It  is  well  to  compare  the  injured 
limb  with  the  uninjured  one  to  determine  whether  eversion  is  a])parent  or 
real,  whether  the  extent  of  possible  eversion  at  the  surgeon's  hands  is 
greater  or  less  on  the  injured  side,  and  whether  the  supposed  fracture 
interferes  with  or  increases  inimrd  rotation,  such  as  is  possible  in  the 
sound  limb.  Inversion  has  been  described  as  occurring  in  some  cases 
only  after  the  lapse  of  a  day  or  two  from  the  time  of  injury.  Violent 
manipulation  to  determine  these  points  is  not  justifiable,  since  other  symp- 
toms are  available  for  diagnostic  purposes. 

Shortening  occurs  in  cervical  fractures  of  the  femur  from  overriding, 
and  from  alteration  of  the  angle  between  the  shaft  and  the  neck.  It 
varies  from  a  mere  fraction  of  an  inch,  to  two,  three  or  even  four  inches. 
It  may  exist  to  its  greatest  degree  immediately  after  the  injury,  or  may 
gradually  increase  with  the  lapse  of  a  few  days.  It  has  been  noticed  to 
occur  suddenly,  when  little  or  no  alteration  in  length  was  apparent  at 
the  first  examination. 

Great  shortening  (l'>  to  3  inches)  occurring  immediately  is  rather  in- 
dicative of  fracture  at  the  base  of  the  neck,  while  slight  immediate 
shortening  followed  by  increased  shortening  is  more  characteristic  of  frac- 
ture at  the  small  part  of  the  neck. 

The  now  well-established  fact  that  femurs  and  tibias  are  often  of  un- 
equal length  in  persons  who  have  never  sustained  injuries  to  the  bones  of 
either  limb  greatly  lessens  the  diagnostic  importance  of  shortening.  If  a 
limb  which  is  a  half-inch  or  one  inch  longer  than  its  fellow  is  fractured, 
and  a  half-inch  or  one  inch  shortening  occurs,  the  two  limbs  when 
examined  by  the  surgeon  will  measure  exactly  the  same,  and  no  evidence 
will  be  derivable  from  such  attempts  at  estimation  of  shortening.  If  the 
shorter  limb  is  subjected  to  traumatism,  shortening  may  seem  to  exist 
when  such  is  not  the  case  ;  or  the  traumatic  diminution  in  length  which 
actually  exists  will  appear  to  be  greater  than  it  is.  Fortunately  the 
normal  difference  of  length  rarely  exceeds  a  quarter-  or  half-inch. 

The  most  practical  method  of  measuring  the  length  of  the  limbs  is  to 
carry  a  tape  measure  from  the  lower  edge  of  each  anterior  superior  spine 
of  the  ilium  to  the  tip  of  the  corresponding  internal  malleolus.  It  is 
well,  perhaps,  to  verify  the  differential  measurement  by  placing  the  upper 
end  of  the  tape  at  the  lower  margin  of  the  umbilicus,  and  holding  it  there 
while  the  lower  end  is  successively  carried  to  the  two  internal  malleoli. 
During  the  measuring  the  pelvis  must  be  horizontal — that  is,  at  a  right 
angle  with  the  median  line  of  the  body — and  the  two  limbs  in  the  same 
condition  of  abduction  and  extension.     The  difficulty  of  obtaining  exactly 


FRACTURES    OF    THE    FEMUR. 


421 


Fig.  234. 


the  same  point  of  measurement  on  the  two  sides,  because  of  the  mobility 
of  the  skin  and  the  want  of  definite  outline  in  the  prominences,  together 
with  the  fallacy  above  mentioned,  have  made  me  place  little  confidence 
in  the  accurate  estimation  of  fracture  shortening. 

The  determination  of  the  relative  position  of  the  two  greater  trochanters 
by  means  of  Nelaton's  line  or  Bryant's  rectangle  is  of  great  value  in 
proving  elevation  or  absence  of  eleva- 
tion of  the  trochanter  on  the  injured 
side.  The  method  is  useful  in  sup- 
posed dislocations  as  well  as  fractures, 
but  will  be  discussed  here.  Nelaton's 
test  line  is  applied  by  carrying  a  string 
from  the  tip  of  the  anterior  superior 
spine  of  the  ilium  to  the  tip  of  the 
tuberosity  of  the  ischium.  The  line 
so  indicated  touches  the  upper  border 
of  the  greater  trochanter,  and  this  re- 
lation is  not  disturbed  by  flexion  and 
extension  of  the  limb.  Displacement 
of  the  trochanter  upward,  from  shoi't- 
enino;  due  to  cervical  fracture,  and  dis- 
placement  downward  or  upward,  as  a 
result  of  dislocation,  are  indicated  by 
comparing  the  two  hips.  The  two 
limbs  must  be  examined  when  neither 
abducted  nor  adducted,  since  in  normal 
limbs  the  former  position  brings  the 
trochanter  above  the  line  and  the  latter 
below  it.  Bryant's  rectangle  consists 
of  two  lines  drawn  while  the  patient 
lies  upon  his  back.  A  vertical  line  is 
dropped  from  the  anterior  supez'ior  spine  of  the  ilium  to  the  bed  ;  toward 
this  line,  at  a  right  angle  to  it,  a  second  line  is  drawn  from  the  upper 
border  of  the  trochanter.  The  last  drawn  line  determines  the  fact  and 
degree  of  elevation  of  the  trochanter  as  compared  with  the  sound  side. 
The  fallacy  due  to  abduction  or  adduction  must  be  remembered  here,  as 
in  using  Nelaton's  line. 

Stimson  uses  Bryant's  method  by  placing  a  small  stick  or  pencil  verti- 
cally against  the  pelvis  in  a  line  with  the  process  and  tuberosity,  and  meas- 
uring from  it  to  the  trochanter.  Morris  estimates  changes  in  distance 
between  the  joint  and  the  trochanter  by  measuring  from  the  outer  surface 
of  the  trochanter  on  each  side  to  the  median  line  of  the  body.  This  is 
readily  done  by  means  of  a  graduated  rod  placed  across  the  pelvis  at  the 
level  of  the  two  anterior  superior  lines  of  the  ilium,  with  its  centre  over 
the  linea  alba,  and  having  upon  each  end  a  sliding  vertical  bar,  which 
can  be  moved  till  it  just  touches  the  outside  of  the  corresponding  tro- 
chanter. These  are  the  simplest  and  most  available  plans  for  determining 
shortening  of  the  neck  or  displacement  of  the  trochanter.  More  compli- 
cated geometrical  methods  introduce  more  sources  of  possible  error. 

Allis  has  called  attention  to  relaxation  of  the  fascia  lata  between  the 
iliac  crest  and  trochanter,  and  above  the  outer  condyle  of  the  femur  in 
fractures  accompanied  by  shortening.  Cleeman  has  directed  the  profes- 
sion to  observe  a  wrinkle  in  the  skin  over  the  ligament  of  the  patella, 
which  will  be  obliterated  when  the  shortening  is  corrected  by  extension. 


Nelaton's  line,  dark.     Bryant's  rect- 
angle, dotted.     (Erichsen.) 


422 


DISEASES    AND    INJURIES    OF    BONES. 


If  shtirteiiing  has  been  detecteil,  its  correction  may  be  attempted  tor  diag- 
nostic and  therapeutic  purposes  by  gentle  traction  and  slight  internal  rota- 
tion,    ^larked   rotary  movements, 
Pig  .,3-*  however,  and  absence  of  support  to 

the  limb  are  liable  to  cause  sepa- 
ration of  fragments  which  may  be 
ini])acted,  and  should  therefore  be 
avoided.  The  shortening  corrected 
by  traction  will  usually  recur  when 
the  traction  is  intermitted,  and  thus 
confirm  the  diagnosis  of  fracture. 
Crepitation  is  a  symptom  of  cer- 
vical fractures  of  great  diagnostic 
value  when  elicited,  but  is  often 
unobtainable.  It  should  seldom 
be  sought  for  with  avidity  be- 
cause of  the  risk  of  separating  im- 
pacted fragments.  Pressure  behind 
the  trochanter  or  traction,  with  or 
without  rotation,  will  often  make 
it  evident ;  but  impaction,  great 
splintering,  wide  separation  of  the 
fractured  surfaces,  or  the  impossi- 
bility of  keeping  the  small  upper 
fragment  steady  in  the  acetabulum, 
often  prevents  its  production.  Cases 
showing  from  other  symptoms  un- 
doubted evidence  of  fracture  should 
not  be  submitted  to  persistent  ma- 
nipulation for  the  production  of  cre- 
pitus. In  obscure  cases  its  develop- 
ment will  not  usually  afford  evidence 
of  sufficient  value  to  warrant  the 
risk  of  detaching  impacted  frag- 
ments. Rubbing  of  the  outer  frag- 
ment or  of  a  dislocated  head  upon  the  ilium  sometimes  simulates  crepitus 
between  two  broken  surfaces.  The  character  of  the  grating  is  softer  than 
in  fracture  crepitus.  Crepitus  is  more  frequently  detected  with  ease  in 
fracture  of  the  base  of  the  neck  than  in  those  of  the  constriction  of  the 
neck,  especially  if  the  fracture  line  runs  into  the  trochanter. 

The  other  symptoms  liable  to  be  found  in  cervical  fractures  are  pain 
referred  to  the  trochanter,  groin,  or  thigh,  tenderness  on  pressure  in  the 
groin  outside  the  femoral  vessels,  swelling  or  diminished  depressibility  at 
the  upper  part  of  thigh,  ecchyraosis  appearing  only  after  two  or  three 
days  have  elapsed,  spasm  of  muscles,  flattening  in  the  trochanteric 
region,  or  enlargement  of  the  trochanter  due  to  splitting  or  comminution. 
The  outer  surface  of  the  trochanter  may  be  further  than  normal  from 
the  middle  line  of  the  body,  nearer  to  it,  or  may  present  no  change  in 
this  respect,  according  as  angular  deformity,  crushing,  and  separation  exist 
alone  or  are  combined.  ]\Iorris's  method  of  investigating  this  symptom 
has  been  discussed. 

It  is  evident  that,  if  the  normal  limb  is  rotated,  the  trochanter  must 
move  in  the  arc  of  a  circle  whose  radius  is  the  distance  between  the 
articular  surface  of  the  head  and  the  outer  surface  of  the  trochanter  ; 


r^ 


Allis's  method  of  testing  relation  of  fascia 
lata. 


FEACTURES    OF    THE    FEMUR.  423 

but,  when  the  neck  is  broken  and  unimpacted,  such  rotation  will  be  in  the 
arc  of  a  circle  whose  radius  is  the  distance  from  the  line  of  fracture  to 
the  trochanteric  surface.  The  second  radius  will  be  shorter,  and  hence 
the  arc  of  rotation  traversed  by  the  trochanter  more  curved.  Such 
change  may  be  estimated  by  placing  the  hand  on  the  outside  of  the 
trochanter  while  an  assistant  rotates  the  limb.  This  test  has  often  been 
recommended  as  worthy  of  diagnostic  credence,  but  it  has  at  my  hands 
been  of  little  service.  If  thickening  of  the  soft  parts  and  a  large  amount 
of  callus  is  detected  in  the  groin,  or  about  the  trochanter  at  the  end  of 
one  or  two  weeks,  fracture  of  the  base  of  the  neck  is  of  course  the  prob- 
able lesion. 

Diagnosis. — The  diagnosis  that  fracture  of  the  neck  of  the  femur 
exists  can  usually  be  made  with  comparative  ease,  but  whether  the  lesion 
is  at  the  constriction  or  at  the  base  of  the  neck  is  a  problem  much  more 
difficult  to  solve.  It  is  not  a  question  worth  attempting  to  answer,  except 
in  those  cases  where  it  is  almost  self-evident.  The  treatment  of  both 
injuries  is  the  same,  the  elaborate  tables  of  supposed  diagnostic  differences 
between  fractures  of  the  constriction  and  of  the  base  have  been  proved 
unreliable,  and  the  endeavor  to  make  an  accurate  diagnosis  is  fraught  with 
great  danger  to  the  future  usefulness  of  the  limb  by  reason  of  breaking 
up  impaction  and  severing  untorn  periosteal  attachments.  When  there 
is  doubt  as  to  the  kind  of  fracture,  or  as  to  whether  fracture,  contusion, 
or  sprain  exists,  always  treat  the  lesion  as  fracture  of  the  base  of  the 
neck,  and  the  result  will  clear  up  the  doubts  in  the  course  of  a  few 
weeks. 

The  symptoms  which  have  just  been  discussed  at  length  will,  when  taken 
in  connection  with  the  history  of  a  fall  and  the  non-existence  of  any  former 
arthritis,  fracture,  or  other  pathological  conditions,  seldom  fail  to  indicate 
that  fracture  of  some  portion  of  the  neck  has  occuri*ed. 

The  differential  diagnosis  of  fractures  of  the  neck  and  dislocations  of 
the  head  of  the  bone  is  important.  Inversion  is  so  rare  in  fracture  that 
its  existence  should  at  once  suggest  posterior  dislocation.  Fracture  with 
inversion  would  not  show  a  flexed,  adducted,  and  such  a  fixed  hip  as  the 
posterior  luxations ;  nor  would  the  presence  of  the  head  of  the  bone  over 
the  iliac  dorsum  or  sciatic  notch,  and  its  absence  from  the  acetabular 
region  be  demonstrable.  In  fracture  with  inversion,  traction  may  convert 
the  inversion  into  eversion  and  correct  the  shortening,  but  not  so  in  dis- 
location. The  anterior  dislocations  are  rare  injuries ;  present  flattening  of 
the  trochanteric  region,  abduction,  and  flexion  of  the  hip,  and  the  unusual 
fulness  or  prominence  at  the  abnormal  site  of  the  head  of  the  bone. 
The  pubic  dislocation  is  accompanied  by  shortening,  the  thyroid  not  by 
shortening  but  by  apparent  lengthening.  In  dislocation  there  is  a  marked 
limitation  of  passive  motion,  and  the  limit  of  possible  mobility  is  reached 
by  a  sort  of  sudden  stopping  or  check  felt  by  the  surgeon's  hands.  In  a 
normal  femur  the  inner  condyle  and  the  head  of  the  bone  always  have 
the  same  direction :  therefore,  the  position  of  the  head  can  be  determined 
in  dislocations  by  observing  the  direction  of  the  inner  condyle.  This  is 
not  true  of  fractures  of  the  femur.  If  there  is  anterior  spinal  curvature 
the  hip  may  be  somewhat  flexed,  and  still  appear  extended.  This  pos- 
sible source  of  error  is  eliminated  by  placing  the  man  on  his  back  and 
flexing  the  opposite  thigh  completely  on  the  abdomen,  when  the  second 
thigh  will  be  raised  from  the  bed,  if  it  be  in  a  state  of  flexion  concealed 
by  the  spinal  curve. 


424  DISEASES    AND    INJURIES    OF    BONES. 

Prognosis. — Patients  with  fractures  of  tlio  femoral  neck  have  died  not 
infretjuently  from  rapid  debility,  severe  arthritis,  or  other  inHammation 
about  the  injury,  or  hypostatic  pneumonia.  Especially  has  this  been  the 
case  in  the  aged.  The  unfortunate  tendency  was  possibly  dependent  in 
some  measure  upon  fat  embolism,  but  more  probably  upon  the  rigid 
confinement  to  bed  with  ('uml)ersome  and  uncomfortable  fracture  dressings, 
which  used  to  be  enforced  for  long  periods.  Our  present  methods  of 
treatment  with  continuous  traction  and  less  absolute  immol)ility  in  bed 
seem  to  permit  a  much  better  prognosis.  The  unfavorable  outlook  so  often 
spoken  of  in  hip  fractures  is  possibly  scarcely  warranted  by  our  present 
experience.  A  certain  amount  of  shortening,  eversion,  stiffness,  and  pain 
often  persists  even  in  fractures  that  have  recovered  with  fibrous  or  osseous 
union  ;  but  fair,  or  even  very  good,  use  of  the  limb  is  not  unusual,  even  in 
old  persons  who  have  apparently  or  certainly  sustained  fracture  of  the 
constriction  of  the  neck.  Even  when  the  fracture  remains  ununited  fair 
walking  is  possible,  because  hypertrophied  muscular  and  tendinous  bands 
may  support  the  pelvis  as  by  a  sling  attached  to  the  greater  trochanter. 

Treatment. — In  treating  fractures  of  the  lower  extremity,  the  firm, 
level  mattress  is  much  more  important  than  in  similar  lesions  of  the  upper 
limb.  A  plain  mattress  made  of  hair,  and  a  bed-pan  for  receiving  the 
dejections,  is  often  preferable  to  any  one  of  the  various  forms  of  fracture 
bed  sold  by  manufacturers.  Careful  nursing  will  prevent  injurious  move- 
ment during  the  use  of  the  bed-pan.  Union  is  to  be  sought  in  all  cases 
of  cervical  fracture,  and  its  acceptance  even  in  faulty  position  is  more 
judicious  than  the  production  of  non-union  or  violent  arthritis  in  the  aged, 
by  reason  of  vigorous  and  repeated  manipulation,  for  the  purpose  of 
establishing  the  exact  line  of  fracture  or  ol)taining  accurate  coaptation.  If 
the  existence  of  dislocation  is  eliminated,  all  doubtful  cases  should  be 
treated  as  fractures  of  the  base  of  the  neck.  Continuous  extension  or 
traction,  applied  l)y  means  of  a  rubber  band  or  weight  attached  to  the 
leg  with  adhesive  plaster  and  lateral  support  to  the  limb  by  means  of  sand- 
bags, as  employed  in  fractures  of  the  shaft  of  the  femur,  is  the  proper 
treatment  for  all  fractures  of  the  neck  of  the  bone.  The  trochanter  may 
be  supported  by  a  small  pad  or  sand-bag  placed  under  it.  This  method 
of  immobilization  is  to  be  kept  up  until  consolidation  of  the  fracture 
takes  place.  Proof  that  union  will  not  occur,  or  satisfactory  evidence  that 
the  injury  was  a  mere  sprain  or  contusion,  indicate  its  discontinuance.  It 
must  also  be  discontinued  if  it  becomes  evident  that  the  patient's  life  is 
endangered  by  the  confinement  to  bed  and  to  one  posture.  Then,  attempts 
at  gaining  union  may  have  to  be  discontinued  in  order  to  prevent  death 
from  failure  of  the  vital  forces.  Even  when  no  union  occurs,  comfort 
is  usually  gained  by  the  rest  given  to  the  joint  and  limb  for  two  or  three 
weeks  by  traction.  Union,  when  it  occurs,  takes  place  in  from  five  to  six 
Aveeks. 

The  extending  force  should  equal  about  six  to  eight  pounds,  while  the 
counter-extension  is  to  be  gained  by  elevating  the  foot  of  the  bed  about 
six  inches,  so  as  to  use  the  weight  of  the  patient's  trunk  as  a  counter-force. 
The  foot  should  be  maintained  in  a  position  with  the  toes  pointing  upward 
and  a  little  oittivard,  which  is  the  normal  posture  of  the  limb  when  a  man 
lies  on  his  back.  Catheterization  will  be  necessary  in  many  patients,  and 
the  occurrence  of  sacral  bedsores  must  be  averted  by  watchfulness  and 
cleanliness. 

In  order  to  get  more  complete  immobility  at  the  seat  of  fracture,  the 
pelvis  and  both  thighs  may  be  encased  in  gypsum  bandages.     In  addition, 


FRACTURES    OF    THE    SHAFT    OF    THE    FEMUR.  425 

a  pad  adjusted  by  a  screw,  passing  through  a  frame  attached  to  the  gypsum 
dressing,  may  be  arranged  to  make  pressure  upon  the  outside  of  the  tro- 
chanter, and  thereby  hold  the  fragments  in  apposition.  This  is  the  char- 
acter of  Senn's  method. 

Gunshot  fractures  of  the  femoral  neck  will  require  provision  for  free 
drainage,  and  perhaps  excision  of  the  head  of  the  bone.  Attempts  to 
fasten  the  capital  fragment  to  the  trochanteric  one  by  screws  and  pegs 
have  been  made  in  the  endeavor  to  avoid  non-union,  but  at  the  present 
time  such  attempts  seem  scarcely  warrantable. 


Fractures  of  the  Shaft  of  the  Femur. 

Fractures  of  the  shaft  of  the  femur  include  those  occurring  in  the  shaft 
of  the  bone  anywhere  except  just  above  the  condyles.  The  latter,  being 
near  the  knee-joint  and  liable  to  special  complications,  are  discussed 
under  Fractures  at  the  Lower  End  of  the  Femur.  Transverse  fracture 
of  the  shaft  is  not  rare  in  children,  but  in  adults  svich  an  occurrence  is 
very  unusual.  In  fractures  of  the  femoral  shaft,  deformity  due  to  over- 
riding and  to  angular  or  rotary  displacement  is  apt  to  be  great.  When 
the  fracture  is  in  the  upper  third,  the  lower  end  of  the  upper  fragment  is 
generally  tilted  outward  and  forward  by  the  great  psoas,  iliac,  and  ex- 
ternal rotator  muscles  of  the  hip,  and  the  upper  end  of  the  lower  fragment 
drawn  upward  and  inward  by  the  flexors  of  the  leg  and  adductors  of  the 
thigh.  This  special  angular  distortion  is  mentioned  because  it  at  times 
compels  the  adoption  of  unusual  methods  of  treatment. 

Symptoms. — The  symptoms  indicative  of  fracture  of  the  femoral  shaft 
are  :  total  loss  of  voluntary  power  in  the  limb,  eversion  of  the  foot  and  leg, 
and  the  usual  concomitants  of  fractures,  deformity,  abnormal  mobility, 
and  crepitus.  Rotation  of  the  limb  is  not  accompanied  by  movement  of 
the  greater  trochanter.  The  deformity  and  flexibility  of  the  thigh  at  the 
seat  of  fracture  are  often  entirely  sufficient  for  diagnosis  without  requir- 
ing successive  attempts  at  getting  crepitus,  which  cause  pain  and  may  do 
harm.  The  shortening,  which  is  chiefly  due  to  the  powerful  muscles  sur- 
rounding the  broken  bone  and  to  the  obliquity  of  the  fracture,  may  be 
very  great,  but  is  overcome  partially,  if  not  entirely,  during  the  continu- 
ance of  strong  traction.  The  estimation  of  the  degree  of  shortening  by 
measuring  is,  as  has  been  mentioned  under  Fractures  Near  the  Hip,  sub- 
ject to  fallacies.  The  symptoms  may  be  a  good  deal  modified  by  impac- 
tion or  interlocking  of  fragments.     This  condition,  however,  is  unusual. 

Union  occurs  in  ordinary  cases  in  about  six  weeks,  after  which  time 
the  patient  may  be  trusted  to  use  crutches,  provided  that  all  possible 
strains  upon  the  repaired  fracture  are  avoided  by  suitable  supporting 
dressings,  and  that  no  weight  is  borne  on  the  injured  limb  in  walking. 
Effusion  into  the  knee-joint  often  occurs  after  the  fracture,  sometimes 
within  a  few  days,  and  occasionally  it  persists  for  many  months.  It  has 
been  attributed  to  involvement  of  the  synovial  membrane;  to  invasion  of 
the  joint  by  the  blood  extravasated  at  the  time  of  fracture ;  to  coincident 
sprain  of  the  knee ;  to  interference  with  venous  return,  and  to  the  posture 
and  prolonged  immobility  of  treatment.  Fractures  at  the  lower  third 
should  be  expected  to  present  this  complication  most  frequently.  It  needs, 
as  a  rule,  no  special  treatment. 

Some  permanent  shortening  is  to  be  expected  after  every  fracture  of 
the  femur ;  but,  if  union  is  obtained  with  the  fragments  in  good  line. 


426  DISEASES    AND    INJURIES    OF    BONES. 

without  rotary  displacement,  a  shortening  of  even  three-quarters  of  an 
inch  will  cause  little  limp  in  the  gait.  Rigidity  of  the  knee  may  remain 
for  a  long  time  in  rheumatic  or  aged  patients.  Open  fractures  of  the 
femur,  especially  if  also  comminuted,  are  rather  dangerous  lesions,  requir- 
ing, in  even  fivvorable  cases,  a  protracted  convalescence. 

In  all  fractures  of  the  femur,  with  rare  exceptions,  permanent  horizontal 
traction,  or  extension,  as  it  is  often  called,  by  means  of  adhesive  phister 
and  attached  weights,  is  the  best  method  of  treatment.  Counter-extension 
is  to  be  obtained  by  elevating  the  foot  of  the  bed  six  inches.  This  pro- 
cedure makes  the  weight  of  the  trunk  act  as  a  counter-extending  force. 
Any  tendency  to  lateral  mobility  or  deformity  of  the  fragments  may  be 
avoided  or  corrected  by  short  coaptation  splints  of  wood,  metal,  or  paste- 
board, or  by  long  narrow  bags,  well,  but  not  too  tensely,  filled  with  sand 
and  laid  closely  along  the  inner  and  outer  sides  of  the  limb.  The  outer 
bag  should  extend  from  below  the  sole  to  within  a  few  inches  of  the 
axilla,  the  inner  bag  from  below  the  sole  to  the  perineum. 

Before  the  application  of  the  plaster  strips  the  thigh  and  leg  should  be 
shaved.     A  piece  of  thin  board,  three  inches  wide  and  five  inches  long,  is 

Fig.  23fi. 


Adhesive  plaster  and  foot-board  applied  for  continuous  extension. 

fastened  lengthwise  to  the  middle  of  the  adhesive  side  of  a  strip  of  rubber 
adhesive  plaster  three  inches  wide  and  six  feet  long.  This  stirrup-like 
apparatus  is  then  smoothly  attached  to  the  limb  by  applying  the  plaster 
up  the  sides  of  the  leg  and  thigh  to  a  point  just  below  the  seat  of  fracture. 
Its  adherence  to  the  skin  is  further  assured  by  applying  narrow  bands  of 
plaster  around  the  limb  and  side  strips  at  three  points — namely,  above  the 
knee,  below  the  knee,  and  about  an  inch  above  the  ankle.  A  bandage  is 
next  applied  over  the  foot  and  malleoli  under  the  stirrup,  and  then  carried 
up  the  limb  over  the  adhesive  plaster  attachment  until  it  nearly  reaches 
the  height  of  the  fracture.  The  terminal  ends  of  the  plaster  which  pro- 
ject above  the  last  fold  of  the  bandage  are  now  turned  over  the  bandage, 
so  that  their  adhesive  surface  becomes  external.  Around  these  turned 
down  ends  the  bandage  is  applied  by  a  few  more  folds,  until  no  vestige 
of  the  plaster  is  seen.  The  attachment  of  the  plaster  to  the  skin  should 
extend  above  the  knee,  in  order  to  avoid  what  might  prove  injurious 
traction  on  its  ligaments.  The  turning  over  of  the  ends  is  additional 
security  against  the  traction  weights  causing  the  adhesive  strips  to  slip  on 
the  skin.  To  the  foot-piece  a  cord  about  three  feet  long  should  be  attached 
so  that  in  the  course  of  an  hour,  when  the  plaster  has  become  firmly 
adherent  to  the  skin,  the  traction  weights  may  be  tied  to  the  apparatus. 
When  it  is  thought  that  the  plaster  will  bear  the  weight  without  slipping, 
the  surgeon  props  up  the  foot  of  the  bed,  and,  taking  hold  of  the  foot  and 
ankle,  makes  powerful  but  steady  traction  to  overcome  the  muscular 
spasm  causing  the  over-riding  and  shortening.   If  there  is  great  shortening. 


FKACTURES  OF  THE  SHAFT  OF  THE  FEMUR. 


427 


or  if  the  patient  is  very  muscular,  it  may  be  well  to  obtain  relaxation  of 
the  muscles  by  producing  a  slight  degree  of  general  ansesthesia  with  ether 
or  nitrous  oxide.  When  the  deformity  has  been  overcome  as  much  as 
possible,  two  or  three  bricks,  or  an  equivalent  weight,  are  tied  to  the  cord 
and  suspended  over  a  pulley  at  the  foot  of  the  bed. 
The  pulley  should  be  placed  high  enough  to  lift  the 
heel  a  little  from  the  mattress,  and  in  such  a  posi- 
tion laterally  as  to  keep  the  axis  of  the  limb  cor- 
rect. The  cord  should  not  let  the  bricks  rest  on 
the  floor  when  the  patient  slides  toward  the  foot  of 
the  bed,  though  it  should  be  long  enough  to  let 
the  patient  slide  up  and  down  for  the  distance  of  a 
foot  or  so.  There  should  be  no  shelf  or  obstacle 
above  the  floor  upon  which  the  bricks  may  catch 
and  suddenly  fall  ofi"  with  a  jerk.  The  pulley  must 
have  side-pieces  or  an  arch  projecting  above  the 
groove,  that  the  cord  may  not  be  pushed  off"  by 
persons  passing  the  foot  of  the  bed. 

Instead  of  using  the  adhesive  plaster  apparatus 
a  series  of  straps  may  be  adopted. 

The  amount  of  weight  for  the  first  three  weeks 
should  be  from  fifteen  to  twenty-five  pounds  for  an 
adult,  according  to  the  muscular  development  and 
tendency  to  spasm.  At  the  end  of  that  time  the 
amount  may  be  decreased  one-half,  and  be  discon- 
tinued at  about  the  sixth  week.  Then  a  circular 
gypsum  or  silicate  of  sodium  dressing  is  applied 
from  the  ankle  to  the  hip,  including  the  pelvis  if 
the  fracture  is  in  the  upper  third,  and  walking  with 
crutches  is  permitted.  The  patient  should  not  bear 
any  of  his  weight  on  the  foot  till  the  tenth  or  elev- 
enth week.  If  the  gypsum  or  silicate  dressing  is 
not  adopted,  sufficient  lateral  support  may  be  ob- 
tained by  using  coaptation  splints  of  moulded  paste- 
board, provided  that  the  knee  and  hip  are  fixed  by 
them.  It  is,  of  course,  understood  that  the  patient 
shall   not  be   permitted  to  walk   even  with   these 

dressings,  unless  the  fracture  has  lost  its  mobility.  Caution  must  be 
exerted  against  subjecting  the  limb  to  strains  or  falls,  for  rupture  of  the 
callus  readily  occurs,  even  as  late  as  three  or  four  months  after  the  original 
injury. 

Usually  a  slight  amount  of  padding  is  required  on  the  bed  beneath  the 
popliteal  space,  because  the  absolutely  straight  position  of  the  knee  be- 
comes painful  unless  a  little  support  is  given  at  the  point  mentioned.  If 
latei'al  deviation  at  the  site  of  fracture  is  not  prevented  by  the  sand-bags, 
or  if  there  is  antero-posterior  bending,  three  or  four  coaptation  splints  of 
wood  eight  to  ten  inches  long  may  be  applied  over  the  bandage  and  kept 
in  place  by  a  few  turns  of  another  bandage.  Pasteboard  or  other  plastic 
material  may  be  moulded  to  the  front  or  side  of  the  thigh,  if  the  surgeon 
prefers.  Care  must  be  taken  that  pressure  of  the  heel  on  the  bed  does 
not  cause  a  bedsore.  A  mass  of  oakum,  wool,  or  cotton,  hollowed  out  like 
a  bird's  nest  to  receive  the  heel,  or  a  pad  placed  beneath  the  tendon  of 
Achilles  so  as  to  lift  the  heel  from  the  mattress,  are  the  simplest  devices 
for  relieving- this  injurious  pressure.    The  bed-clothes  must  not  rest  on  the 


Levis's  pulley  for  con- 
tinuous traction  appa- 
ratus. 


428 


DISEASES    AND    INJURIES    OF    BONES. 


toes,  siuce  their  weight  will  pref^s  the  foot  outward  and  evert  the  leg. 
Any  sort  of  an  arched  frame,  such  as  can  be  made  from  pieces  of  barrel 
hoop  placed  over  the  foot,  will  hold  the  coverings  up. 

It  is  also  necessary  to  see  that  the  patient  lies  flat  on  his  back,  for  if  he 
turns  a  little  on  his  side,  or  if  the  pelvis  sinks  into  the  mattress  on  one 
.side,  while  the  foot  and  leg  are  held  motionless  by  the  dressing,  rotary 
deformity  will  remain  when  the  fracture  is  united.  The  foot  should  be 
kept  very  slightly  everted,  as  has  been  stated  under  the  treatment  of 
Fractures  Near  the  Hip.  The  j)atient  should  not  be  allowed  to  sit  up  in 
bed  nor  have  a  high  pillow  or  bolster,  until  at  least  three  weeks  have 
elapsed.  Then  he  may  be  propped  up  in  the  half-sitting  posture,  if  it 
shows  no  tendency  to  displace  the  partially  united  fracture.  The  sliding 
movements  up  and  down  in  the  bed,  which  are  permissible  from  the  begin- 
ning, relieve  the  monotony  of  confinement  very  much,  and  enable  the 
nui'se  to  adjust  the  bed-pan  and  keep  the  patient  clean. 

When,  in  fractures  of  the  upper  third,  there  is  marked  tilting  forward 
of  the  upper  fragment,  the  straight  position  just  described  is  not  always 
satisfactory.  It  may  become  necessary  to  elevate  the  lower  fragment,  in 
order  to  meet  the  displaced  upper  fragment  and  preserve  the  proi)er  axis 
of  the  limb.  In  order  to  get  proper  apposition  of  the  fragments  the  limb 
with  the  traction  apparatus  attached  should  be  elevated  upon  an  inclined 


■|i|ni  I    iiiiiiijliun    i^"-"^-^"- —      'ii     ill 

Inclined  plane  and  extension  apparatus. 


(Agnkw.) 


plane  of  wood  and  maintained  in  that  position  during  the  treatment.  The 
weight  extension  can  readily  be  continued  at  the  same  time.  Whether 
the  inclined  plane  is  such  as  will  keep  the  knee  straight  or  flexed  is  a 
matter  of  comparative  inditiference. 


Ftr;.  2;!9. 


Double  inclined  plane  fracture  box. 

In  treating  open  fractures  with  much  suppuration  a  long  fracture  box 
or  the  anterior  wire  splint  of  Nathan  R.  Smith  are  often  convenient.  The 
method  of  using  the  anterior  splint  is  shown  in  the  illustration,  except 


FRACTURES    OF    THE    SHAFT    OF    THE    FEMUR.  429 

that  the  pulley  should  be  placed  over  the  middle  of  the  leg  so  as  to  obtain 
extension  or  traction  by  the  weight  of  the  buttock. 

Fig.  240. 


Smith's  anterior  splint. 

In  infants  below  five  years  it  is  often  difficult  to  prevent  soiling  of  the 
traction  apparatus  by  the  alvine  discharges ;  hence,  vertical  extension  has 
been  employed  with  good  results.  This  is  effected  by  flexing  both  hips 
at  a  right  angle,  placing  straight  splints  along  the  posterior  surfaces  of 
the  limbs  to  prevent  flexion  of  the  knee,  and  attaching  the  feet  to  a  sup- 
port over  the  bed.  The  buttocks  thus  act  as  a  traction  weight  and  the 
little  patient  can  be  kept  clean.  If  preferred  a  pulley  and  a  weight  of 
four  or  five  pounds  attached  to  the  leg  and  foot  may  be  used  to  increase 
the  traction  power.  When  the  child  is  over  four  or  five  years  of  age  the 
ordinary  horizontal  traction  is  easily  employed.  The  weight  should  be 
about  one  pound  for  every  year.  Union  becomes  firm  in  children  in  about 
four  weeks. 

Fractures  of  the  Lower  End  of  the  Femur. — These  injuries, 
occuring  so  near  the  knee-joint  and  having  a  short  lower  fragment,  which 
may  be  difficult  to  control,  deserve  some  special  consideration.  The  line 
of  fracture  may  be  in  the  shaft  just  above  the  condyles,  may  at  the  same 
time  run  dowward  between  the  condyles,  splitting  them  apart,  or  may  not 
involve  the  shaft  at  all  but  merely  separate  one  of 
the  condyles  or  a  part  of  a  condyle  from  the  rest  of  Fig.  241. 

the  bone.     Sometimes  small  pieces  of  the  bone  are  m,  •,.'(;  pw| 

torn  up  by  strains  on  the  crucial  ligaments.     The  "  >  i' 

last  two  varieties  are  very  rare.  \ 

The  epiphysis,  which  includes  the  entire  condy- 
loid portion  of  the  bone,  may  be  detached  in  per- 
sons not  over  twenty  years  of  age.     The  line  of 
fractures  just  above  the  condyle  is  usually  oblique, 
but  a  transverse  direction  is  said  to  be  more  com- 
mon than  when  the  bone  is  broken  at  a  higher 
point.     The  lower  fragment  in  fractures  above  or        Separation    of  lower 
through  the  condyles  is  frequently  displaced  back-     femoral  epiphysis.  (Brt- 
ward  and  may,  by  pressure  upon,  or  laceration  of,     a-'^t.) 
the  popliteal  vessels,  cause  gangrene  of  the  leg. 
The  same  result  may  follow  similar  displacement  of  the  upper  fragment. 

The   usual  symptoms  of  fracture  are  present.     The  lateral  mobility 
possible  above  the  knee,  the  backward  displacement  of  the  lower  frag- 


430  DISEASES    AND    INJURIES    OF    BONES. 

ment  and  the  leg,  and  the  prominence  and  unusual  mobility  of  the  patella 
in  supra-condyloid  fracture,  or  its  sinking  between  the  separated  condyles 
in  inter-condyloid  fractures,  are  additional  aids  to  diagnosis.  A  pointed 
upper  fragment  is  sometimes  driven  into  the  fibres  or  tendon  of  the  four- 
headed  extensor  muscle  or  thrust  through  the  integument.  Effusion  or 
hemorrhage  into  the  knee-joint  is  particularly  common  in  fractures  in- 
volving the  condyles. 

Death  from  suppurative  arthritis  or  gangrene,  though  not  frequent,  is 
a  possibility  to  be  remembered  in  giving  a  prognosis ;  and  more  or  less 
ankylosis  of  the  knee  is  quite  usual,  especially  when  the  joint  is  invaded 
by  the  fracture  line. 

The  proper  treatment  is  permanent  horizonal  traction,  as  in  fracture  of 
the  shaft,  with  even  greater  care  to  keep  the  knee-joint  immovable.  This 
immobility  may  be  attained  by  a  pasteboard  splint  adjusted  to  the  back 
of  the  joint.  The  adhesive  strips  for  traction  should  extend  along  the 
limb  only  as  far  as  the  knee.  If  the  straight  posture  does  not  maintain 
the  lower  fragment  in  proper  position,  the  knee  may  be  partially  flexed  by 
placing  a  pillow  or  a  double  inclined  plane  under  it,  or  by  using  a 
Smith's  anterior  splint.  Severe  arthritis  is  an  argument  for  the  com- 
pletely extended  position,  since,  if  ankylosis  occurs,  a  straight  knee  is 
more  useful  than  a  slightly  flexed  one.  If  the  distention  of  the  joint 
with  fluid  is  too  great  to  allow  the  joint  to  be  completely  extended,  the 
fluid  may  be  partially  withdrawn  with  an  aseptic  aspirator  needle. 

If  spasm  of  the  gastrocnemius  muscle  prevents  adjustment  of  the  lower 
fragment,  tenotomy  of  the  tendon  of  Achilles  may  be  justifiable,  to 
weaken  the  displacing  cause.  If  the  upper  fragment  is  buttonholed  and 
so  tightly  held  in  the  substance  of  the  extensor  tendon  that  reduction  of 
the  fracture  is  impossible,  its  liberation  by  subcutaneous  or  open  section 
of  the  muscle  is  proper.  Arthritis,  if  severe,  requires  appropriate  treat- 
ment. The  formation  of  pus  in  the  joint  is  a  demand  for  immediate  in- 
cision under  antiseptic  measures. 

Fracture  of  a  single  condyle  is  a  very  rare  injury  and,  owing  to  the 
slight  deformity  attending  it,  may  be  mistaken  for  a  sprain  or  arthritis  of 
the  knee.  The  integrity  of  the  other  condyle  and  the  attachment  of  the 
broken  piece  of  bone  to  the  tibia  prevent  shortening  and  marked  displace- 
ment. Suppuration  of  the  joint  has  followed  condyloid  fracture.  The 
diagnosis  is  to  be  made  from  localized  pain  and  ecchymosis,  motion  and 
crepitus.  Horizontal  traction  witli  care  to  correct  any  lateral  deviation 
at  the  knee  is  the  treatment;  though  a  long  fracture  box  or  a  posterior 
splint  may  do  equally  well.  The  joint  should  be  kept  immovable  for 
three  or  four  weeks.  These  fractures,  and  those  in  which  small  splinters 
of  bone  are  torn  off  Avithin  the  joint,  resemble  in  their  symptoms  severe 
sprain,  and  should  receive  much  the  same  treatment. 


Fractures  of  the  Patella. 

Pathology. — The  patella  is  broken  generally  by  sudden  and  forcible 
contraction  of  the  four-headed  extensor  of  the  leg,  and  occasionally  by 
direct  violence.  The  patient  usually  attributes  the  fracture  to  the  fall 
upon  the  knee  ;  but  the  fall  in  most  cases  is  due  to  the  previous  giving 
way  of  the  patella  from  muscular  strain  exerted  upon  it,  for  it  is  a  sesa- 
moid bone  in  the  tendon.  A  slip  of  the  foot  occurs,  and,  as  the  man  tries 
to  save  himself  from  falling,  the  violent  muscular  contraction  bends  the 


FRACTURES  OF  THE  PATELLA. 


431 


patella  across  the  condyles  and  fractures  it  by  the  cross-breaking  strain, 
or  else  tears  it  asunder  simply  by  the  powerful  traction  upward.  A 
similar  result  may  occur  in  efforts  at  kicking  or  lifting.  This  usual  causa- 
tion of  the  fracture  is  proved,  in  the  history  of  some  cases,  by  the  fact 
that  in  falls  upon  the  bent  knee  the  impact  is  received  on  the  head  of  the 
tibia  rather  than  on  the  patella,  and  by  the  further  circumstances  that 
the  line  of  fracture  is  usually  transverse,  that  in  fractures  known  to  be 
caused  by  direct  violence  the  bone  shows  vertical,  oblique,  or  comminuted 
fractures,  and  that  no  bruise  is  seen  over  the  patella  in  the  ordinary 
cases. 

The  fracture  from  muscular  contraction  is  usually  more  or  less  trans- 
verse, is  situated  near  the  middle  of  the  bone,  and  is  generally  repaired 
by  fibrous  union.  Comminuted  and  oblique  fractures  visually  unite  by 
bony  instead  of  fibrous  tissue. 


Fig.  242. 


Fig.  24.3. 


Fig.  244. 


Transverse  fracture  of 
patella. 


Oblique  fracture  of 
patella. 


Bony  union  of  comminuted  frac- 
ture of  patella.     (Gurlt.) 


The  transverse  fracture,  from  muscular  action,  is  so  much  more  common 
than  any  other  that  the  subsequent  description  refers  to  it,  unless  other- 
wise stated.  The  lower  fragment  retains  its  normal  position  ;  but  the 
upper  one  is  drawn  upward  by  the  muscle  and  pushed  upward  by  the 
rapidly  occurring  intra-articular  effusion,  until  the  separation  amounts  to 
half  an  inch  or  an  inch.  If  the  muscular  aponeurosis  surrounding  the 
bone  is  greatly  torn,  the  displacement  may  be  much  greater ;  and,  on  the 
other  hand,  if  the  fibrous  envelope  is  not  ruptured,  the  fragments  may 
remain  in  contact.  Lateral  displacement  may  at  times  occur,  but  in  any 
marked  degree  is  not  common.  Some  tilting  of  the  fragments  due  to  the 
surgeon's  dressing  or  to  the  intra-articular  effusion  is  not  unusual.  The 
fragments  may  thus  be  tilted  so  that  they  are  in  contact  at  one  side,  but 
separated  at  the  other,  or  may  be  so  everted  that  the  fractured  surfaces 
are  directed  in  an  anterior  direction. 

Symptoms. — The  symptoms  are  a  sudden  loss  of  extending  power  at 
the  knee,  often  accompanied  by  a  sharp  snap  at  the  moment  the  bone 
gives  way ;  pain,  difficult  progression,  though  walking  is  often  possible 
if  care  is  taken  to  keep  the  tibia  and  femur  in  a  straight  line  and  the 
heel  to  the  ground ;  a  well-marked  furrow  felt  with  the  finger  between 
the  fragments,  independent  mobility  of  the  upper  and  lower  parts  of  the 
bone,  with  crepitus  when  they  are  pressed  together  and  moved  laterally ; 
and  swelling  of  the  knee  from  blood  and  inflammatory  products  within 
the  synovial  cavity  of  the  joint  and  the  surrounding  structures.  The 
arthritis  accompanying  the  fracture  does  not  give  rise  to  the  intense  pain 


432 


DISEASES    AXD    INJURIES    OF    BONES. 


SO  common  in  other  cases  of  synovitis  of  the  knee,  probably  because  the 
tearing  open  of  the  joint  prevents  intra-articular  tension.  The  patient 
is  unable  to  extend  the  knee  after  it  has  been  Hexed,  or  to  raise  the  foot 
from  the  surface  of  the  bed  upon  which  he  lies.  The  disability,  however, 
varies,  as  would  be  expected,  with  the  amount  of  laceration  of  the  tendi- 
nous aponeurosis  surrounding  the  patella.  The  bone  has  the  vastus  mus- 
cles inserted  into  its  lateral  margins  and  the  general  a{)oneurosis  spread 
over  its  front.  Hence,  extension  of  the  knee  may  be  accompanied  to  a 
limited  degree  by  such  untorn  attachments,  even  after  fracture  of  the 
patella.  In  vertical  and  many  comminuted  fractures  the  extending 
power  will  be  interfered  with  only  by  reason  of  pain.  The  joint-effusion 
will  be  absent  if  the  case  is  seen  immediately  after  the  injury. 

The  diagnosis  is  readily  made  by  palpation  and  the  symptoms  above 
described.  Fractures  with  little  or  no  separation,  and  traumatic  bursitis 
in  which  the  bursa  in  front  of  the  patella  is  filled  with  blood  and  inflam- 
matory products,  may  need  careful  consideration  before  a  correct  under- 
standing of  the  lesion  is  obtained.  It  is  said  that  crepitus  and  the  feeling 
of  separated  bony  fragments  may  be  simulated  by  blood-clots  in  the  bursa. 
The  filling  of  the  prepatellar  bursa  with  fluid  secreted  by  its  own  wall,  or 
with  synovia  entering  it  from  the  joint,  with  which  communication  is 
mutually  established  by  means  of  laceration  of  the  bursa  and  the  cleft 
in  the  bone,  may  prevent  accurate  determination  of  the  exact  line  of 
fracture.  After  about  ten  days  have  elapsed  the  swelling  of  the  joint 
decreases,  and,  if  the  pieces  of  bone  are  in  close  contact,  a  short  fibrous, 
in  rare  cases  an  osseous,  bond  of  union  is  established. 

The  fibrous  union  is  often  a  long  one,  even  measuring  three  to  four 
inches,  and  the  separation  of  the  fragments  may  increase  on  flexion  of 
the  knee  if  the  upper  fragment  has  become  adherent  to  the  structures  on 
the  front  of  the  thigh.  Sometimes  the  bond  of  connection  is  little  more 
than  a  condensation  of  the  fascial  structures,  and  seems  not  to  partake  of 
the  nature  of  an  attempt  at  repair.  Use  of  a  quite  well-repaired  fracture 
of  the  patella  has  often  caused  the  fibrous  union  to  stretch,  and  stretching 
may  be  greater  on  one  side  than  on  the  other.     Osseous  union  occasion- 


FiG.  245. 


Fig.  246. 


\"  -■*^'t': 


Bony  union  of  fractured  patella. 
(Beyant.) 


Close  ligamentous  union  resembling  bony  union. 
(Levis's  specimen  in  Mutter  Museum.) 


ally  takes  place,  but  many  close  fibrous  unions  have  been  mistaken  during 
life  for  bony  repair.  Xodules  of  bone  are  at  times  found  in  the  fibro- 
ligamentous  tissue  between  the  fragments.  Rupture  of  the  bond  holding 
the  pieces  together,  or  fracture  near  the  point  of  union,  is  not  infrequent. 


FRACTUEES  OF  THE  PATELLA. 


433 


Such  secondary  accidents  show  at  times  little  attempt  at  union.  When 
the  tissues  have  become  rigid  and  adherent  about  the  seat  of  fracture,  and 
there  still  remains  some  stiffness  of  the  joint,  the  integument  may  be 
torn  and  the  joint  laid  open  at  the  time  the  secondary  fracture  occurs. 
The  open  fractures  so  caused  or  originally  open  are,  of  course,  very  serious 
injuries. 

Fig.  247. 


\ 


Ununited  fracture  of  patella,,  from  cast. 

A  severe  arthritis  may  leave  a  very  stiff  knee  ;  and,  even  in  ordinary 
cases,  free  motion  of  the  limb  is  not  attained  for  six  months  or  a  year. 
This  is  partly  due  to  the  fear  of  tearing  or  stretching  the  ligamentous  union 
by  early  attempts  at  motion,  which  induces  the  surgeon  and  the  patient 
to  insist  upon  protracted  wearing  of  splints  and  abstinence  from  strong 
passive  movements.  The  fear  is  a  well-grounded  one.  After  freedom  of 
flexion  and  extension  of  the  joint  has  finally  been  gained,  the  disability 
from  fibrous  union,  even  an  inch  in  length,  is  not  very  great.  The  patient 
may  scarcely  limp ;  though  a  rapid  gait  or  the  ascending  and  descending 
of  stairs  will  show  his  imperfect  power  of  control  over  the  knee.  Going 
down  stairs  is  especially  troublesome.  Active  extension  of  the  joint  will 
probably  be  possible  only  when  the  limb  is  put  in  an  almost  straight  po- 
sition. 

Treatment. — In  treating  fracture  of  the  patella,  inflammation  of  the 
joint  should  be  moderated  and  a  short  bond  of  union  secured.  These 
at  least  are  the  objects  to  be  sought.  Usually  rest  is  all  that  is  required 
to  effect  the  first  result.  Cooling  lotions  may  be  employed  if  the  arthritis 
promises  to  be  severe.  "When  there  is  very  great  intra-articular  effusion, 
existing  as  late  as  ten  days  or  two  weeks  after  the  receipt  of  injury,  aspi- 
ration of  the  joint  with  an  aseptic  aspiration  needle  may  be  performed. 
The  small  size  and  irregular  margins  of  the  fragments,  their  being  imbedded 
in  a  tendinous  aponeurosis  which  is  attached  to  the  bone  at  the  anterior 
edge  of  its  margins,  and  the  convex  surface  of  the  condyles  on  which  the 
fragments  rest,  all  make  accurate  adjustment  by  encircling  dressings 
difficult  and  unsatisfactory. 

The  best  treatment  for  the  majority  of  cases  is  obtained  by  drawing  the 
fragments  together  by  means  of  steel  hooks  thrust  through  the  skin  and 

28 


48i 


DISEASES    AN'l)    INJURIES    OF    BONES. 


imbedded  iu  the  tendon  above  and  below  the  upper  and  lower  fragments 
respectively.  The  hooks  devised  by  INIalgaigne  are  effective,  but  on 
account  of  the  irregular  shape  of  the  bone  do  not  permit  as  accurate  co- 
aptation as  do  those  devised  by  Levis.  These  latter  are  separated  pairs 
and  can,  therefore,  be  introduced  parallel  to  each  other  or  at  an  angle ; 
varying  with  the  line  of  fracture  and  tendency  to  irregularity  in  the  dis- 
placement. Each  pair  of  hooks  has  its  points  held  together,  after  coap- 
tation of  the  fragments,  by  a  screw  or  by  a  lateral  clani]). 


Fig.  24S. 


Fi.;.  24',). 


Levis's  modification  of  Malgaigne's  patella  hook. 


To  get  rid  of  the  muscular  displacing  cause  the  leg  should  be  kept 
fully  extended  on  the  thigh,  and  the  thigh  perhaps  slightly  flexed  on  the 
pelvis.  This  is  readily  done  by  elevating  the  limb  on  an  inclined  plane ; 
or  by  supporting  it  with  pillows  after  placing  any  form  of  rigid  splint 
behind  the  knee.  This  position  relaxes  the  three  muscular  masses  arising 
from  the  femur  and  also  the  rectus,  which  has  its  origin  from  the  pelvis. 
Absolute  rest  in  this  position  for  about  a  Aveek,  Avith  perhaps  the  applica- 
tion of  cooling  lotions,  Avill  cause  absorption  of  the  articular  effusion  which 
aids  in  separating  the  fragments.  If  it  does  not,  asi)iration  is  justifiable. 
At  the  end  of  this  time  the  fragments  can  usually  be  pressed  together 
by  the  surgeon's  fingers  and  held  while  the  hooks  are  in.serted,  .so  as  to 
keep  them  closely  approximated.  It  is  best  to  put  the  loAver  hook  of  the 
pair  in  position  first ;  and  then  the  upper  fragment,  Avhich  is  the  displaced 
one,  can  be  controlled  by  the  insertion  of  the  second  hook. 

The  points  of  the  hooks  must  be  sharp,  and  should  be  thrust  as  deeply 
as  possible  into  the  tendon  close  to  the  margin  of  the  bone.  There  is  no 
danger  of  entering  the  joint,  for  the  tendon  is  very  thick  and  tough.  After 
one  pair  has  been  inserted  the  other  is  to  be  placed  Avhere  it  will  best 
hold  the  fragments  firmly  together.  The  skin  should  be  drawn  tightly 
over  the  knee-pan  before  the  hooks  are  inserted,  and  both  the  surface  of 
the  skin  and  the  hooks  cleaned  and  made  aseptic.    Ether  may  be  required 


FEACTUEES    OF    THE    PATELLA.  435 

in  some  patients,  since  the  operation  is  rather  painful,  though  not  a  tedious 
one.  The  points  of  puncture  and  the  surrounding  skin  should  be  dusted 
Avith  boric  acid  or  iodoform,  and  the  parts  surrounded  with  a  dressing  of 
dry  antiseptic  cotton  or  gauze. 

The  hooks  should  be  kept  in  place  for  six  weeks ;  and,  when  removed, 
the  patient,  though  using  crutches,  should  wear  a  posterior  splint  for  five 
or  six  weeks  longer,  in  order  not  to  tear  the  broken  bone  asunder  by  sud- 
denly flexing  the  joint.  Sometimes  the  hooks  may  need  tightening  once 
or  twice  as  the  swelling  subsides,  but  usually  no  change  is  required.  Their 
removal  from  the  first  punctures  is  not  to  be  expected  until  they  are 
finally  taken  out.  The  irritation  produced  by  the  hooks  is  inconsiderable. 
If  a  tendency  to  erysipelas  or  abscess  about  the  punctures  is  feared  because 
of  the  unhealthy  condition  of  the  patient  or  for  any  other  reason,  the 
hooks  should  not  be  applied  ;  or,  if  already  applied,  they  should  be  re- 
moved. Under  such  circumstances  the  adhesive  plaster  dressing  is  proba- 
bly as  simple  and  etficient  as  any. 

The  adhesive  plaster  dressing  is  applied  as  follows  :  After  the  knee  has 
been  extended  and  the  entire  limb  elevated,  the  middle  of  a  strip  of  adhe- 
sive plaster  about  two  feet  long  is  placed  on  the  skin  beneath  the  loAver 
patellar  fragment,  and  its  ends  carried  upward  and  crossed  upon  the  back 
of  the  thigh.  By  two  or  more  strips  applied  in  a  similar  manner,  but 
not  exactly  corresponding  with  the  first,  the  lower  fragment  is  steadied. 
Then  similar  overlying  strips  are  placed  above  the  upper  fragment  and 
used  to  draw  it  down  toward  the  lower  one.  The  ends  are  crossed  on  the 
back  of  the  calf  of  the  leg.  Over  the  whole  a  roller  bandage  is  applied 
from  foot  to  hip,  and  the  limb  kept  extended  and  elevated  by  an  inclined 
plane.  Renewal  of  the  adhesive  plaster  will  be  required  about  once  a 
week,  during  the  six  weeks  that  the  dressing  is  used  before  permitting  the 
patient  to  be  up  on  crutches.  In  applying  this  and  similar  constricting 
dressings  there  is  a  great  tendency  to  tilt  the  fragments  so  that  the  ante- 
rior edges  of  the  broken  surfaces  are  further  apart  than  the  posterior. 
Perhaps  this  may  be  avoided  by  one  or  two  strips  carried  directlv  around 
the  front  of  the  knee-joint. 

For  a  long  time  after  discarding  all  apparatus  and  crutches  the  patient 
should  support  the  patella  by  wearing  a  knee-cap  of  elastic  webbing. 

Open  fractures  of  the  patella  should  be  treated  by  free  incision  into 
the  joint,  washing  out  the  'synovial  sac  with  a  five  per  cent,  solution  of 
carbolic  acid,  a  sublimate  solution  (1  :  2000),  or  beta-naphthol  solution 
(1  :  2500),  and  free  drainage  by  tubes.  If  the  opening  is  very  small 
and  the  injury  just  received,  the  attempt  to  convert  the  fracture  into  a 
closed  one  without  free  incision  may  be  proper ;  but  the  first  sign  of  joint 
inflammation  is  a  signal  for  free  incision,  antiseptic  washing,  and  drainage. 
The  use  of  the  hooks  or  the  adoption  of  a  simple  posterior  splint  to  main- 
tain the  extended  position  will  necessarily  be  the  treatment  in  all  such 
cases,  since  the  adhesive  plaster  dressing  and  similar  devices  can  scarcely 
be  applied.  The  drainage-tube  need  not,  as  a  rule,  be  retained  over  a 
week. 

Rupture  of  the  bond  of  union  or  refracture  of  the  patella  should  be 
treated  as  the  original  fracture.  Sometimes  the  tendon  of  the  great 
extensor  mass  of  muscles  is  torn  from  the  upper  edge  of  the  patella  by 
the  same  mechanism  that  usually  breaks  the  bone.  The  treatment,  a^ 
well  as  the  symptoms,  is  similar. 

The  treatment  of  fractured  patella  by  wiring  the  fragments,  and  the 
management  of  cases  with  long  fibrous  union  by  resection  and  wiring  are 


436  DISEASES    AND    INJURIES    OF    BONES. 

not  jujitifiable.  The  disability  resulting  from  imperfect  connection  of 
the  fragments  is  not  great  enough  to  warrant  the  additional  though  slight 
risk  to  life  assumed.  Such,  at  least,  is  my  opinion.  I  am  prepared  to 
have  the  fracture  in  my  own  person  treated  by  the  hooks,  but  not  by 
wiring.     Therefore,  I  recommend  one  and  condemn  the  other. 


Fractures  of  the  Tibia  and  Fibula. 

The  tibia  and  fibula  are  each  developed  by  three  ossific  centres,  one  for 
the  shaft  and  one  for  each  extremity.  The  upper  epiphyses  unite  at  about 
twenty-five  years  of  age,  the  lower  at  about  twenty  years.  Occasionally 
the  tubercle  and  malleolus  of  the  tibia  develop  from  separate  centres. 
The  possibility  of  ejjiphyseal  separations  occurring  when  the  bones  of  the 
legs  are  subjected  to  violence  should  be  recollected.  Such  diastases  are, 
however,  very  rare. 

Fractures  Near  the  Knee. — Fractures  at  the  upper  end  of  the 
tibia,  wdiich  usually  are  accompanied  by  fibular  fracture,  are  frequently 
transverse,  and  may,  by  more  or  less  vertical  lines,  invade  the  knee-joint. 
If  the  fibula  is  neither  broken  nor  dislocated,  it  aids  in  preventing  dis- 
placement. Epiphyseal  separation  here,  as  elsewhere,  is  liable  to  inter- 
fere with  growth  of  the  bone  in  length.  Hence  the  uninjured  fibula  as 
it  grows  must  either  become  bowed  or  dislocated  at  one  of  its  ends. 

The  usual  symptoms  of  fracture  may  be  associated  with  those  of  syno- 
vitis of  the  knee,  or  of  injury  to  popliteal  vessels  and  nerves.  The  prog- 
nosis is  seriousbecauseof  the  possibility  of  ankylosis,  suppurative  arthritis, 
and  other  complications.  The  fibula  is  seldom  broken  at  its  upper  end, 
except  when  the  tibia  also  is  fractured. 

Fractures  of  the  Sftaft  of  the  Tibia  and  Fibula.  Pathol- 
ogy.— The  tibia  alone  is  seldom  broken  except  when  the  fracture  is  due 
to  direct  violence,  such  as  a  kick  on  the  shin.  The  line  of  fracture  is 
then  apt  to  be  somewhat  transverse.  The  fibula,  being  the  smaller  bone, 
may  readily  be  broken  while  the  tibia  remains  intact.  If  both  bones  are 
involved,  the  fibula  is  likely  to  give  way  at  a  higher  point  than  the  tibia. 
The  most  common  point  of  fracture  of  the  bones  of  the  leg  is  near  the 
junction  of  the  middle  and  lower  thirds,  and  a  frequent  displacement  is 
projection  of  the  upper  fragment  forward  and  inward  while  the  lower 
fragment  is  drawn  upward,  behind  the  upper  fragment,  by  the  great 
muscles  of  the  calf.  The  subcutaneous  situation  of  the  tibia  makes  per- 
foration of  the  integument  and  the  conversion  of  the  fracture  into  an  open 
one  quite  frequent. 

Symptoms. — The  symptoms  of  fracture  are  easily  discernible,  especially 
when  both  bones  are  broken,  since  mobility  and  deformity  are  then  pres- 
ent to  a  greater  extent  than  under  the  opposite  condition.  The.  tibial 
crest  and  inner  surface  are  so  easily  felt  through  the  thin  overlaying  tis- 
sues that  deviation  in  outlines  here  can  scarcely  be  missed  unless  sufficient 
time  has  elapsed  for  the  development  of  the  great  swelling  which  so  often 
happens.  Patients  have  occasionally  the  ability  to  walk  upon  a  broken 
tibia,  and  even  when  both  bones  are  fractured  such  a  feat  is  not  impossible. 
Walking  after  fracture  of  the  fragile  fibula  is  neither  surprising  nor 
uncommon.  If  it  has  been  ascertained  that  the  tibia  is  broken,  fracture 
of  the  fibula  may  usually  be  assumed,  unless  the  history  is  that  of  an 
injury  of  a  localized  character  received  in  the  tibial  region.  If  the  fact 
is  not  evident  from  the  general  deformity  and  preternatural  mobility  of 


FRACTURES    OF    THE    TIBIA    AND    FIBULA. 


437 


the  limb,  pressure  along  the  fibula  may  perhaps  elicit  pain,  crepitus,  or 
yielding  sufficient  to  establish  the  fact  of  its  fracture. 

When  such  evidence  is  not  at  once  obtained,  repeated  and  vigorous 
attempts  at  developing  symptoms  of  fracture  of  the  fibula  are  not  wise 
or  justifiable,  unless  the  treatment  is  to  be  influenced  by  such  knowledge, 
which  is  rarely  the  case.  The  formation  of  blebs  on  the  surface  of  the 
leg,  great  swelling,  violent  cellulitis,  and  fat  embolism  are  not  unusual 
accompaniments  of  the  severe  injuries  that  give  rise  to  fractures  of  the 
leg  bones. 

Union  in  uncomplicated  cases  of  tibial  fracture  is  fii-m  in  five  or  six 
weeks ;  in  fibular  fracture  in  from  three  to  four.  The  bridge  of  callus 
occasionally  uniting  the  bones  after  cure  is  of  no  evil  consequence,  since 
rotation  is  not  a  function  of  the  leg  and  foot,  as  it  is  in  the  upper  extrem- 
ity. Non-union  is  not  so  very  infrequent,  and  when  occurring  is  probably 
often  occasioned  by  imperfect  immobilization  due  to  faulty  dressings. 
Comminuted  and  very  oblique  fractures  require  more  time  for  consolida- 
tion. Neuralgic  and  rheumatic  pains,  persistent  oedema,  rigidity  of  the 
ankle,  and  chronic  ulcers  from  defective  restoration  of  circulation  are  not 
unusual  sequences  of  fractures  iti  the  leg. 

Fractures  of  the  Tibia  and  Fibula  near  the  Ankle. 
Pathology. — These  injuries  are  frequent  and  often  very  serious  injuries- 


Fig.  250. 


Fig.  251. 


Vertical  section  of  bones  at  ankle- 
joint.      (TiLLAUX.) 


Deformity  after  a  bad  fracture 
at  the  ankle.  .  (Smmson.) 


Both  bones  may  be  broken  without  complication,  they  may  be  greatly 
shattered  with  the  ankle-joint  involved,  the  fibula  alone  may  be  fractured, 


438 


DISEASES    AND    INJURIES    OF    BOXES. 


or  one  or  both  malleoli  may  be  separated  from  the  corresponding  shaft. 
The  lower  end  of  the  tibia  is  scarcely  ever  broken  without  the  fibula 
being  similarly  injured,  though  the  fracture  of  the  latter  bone  may  be 
two  or  three  iliches  above  its  tip.  In  making  this  statement  I  refer  to 
the  base  of  the  tibia  and  not  to  its  malleolus,  which  can  readily  be 
chipped  off  without  the  fibula  sustaining  any  fracture. 

On  account  of  the  mortise-like  manner  in  which  the  astragalus  fits 
between  the  malleoli,  lateral  mobility  of  the  normal  ankle-joint  is  impos- 
sible, though  it  is  simulated  during  the  extended  position  of  the  foot  by 
the  slight  rotation  about  a  vertical  axis  which  is  possible.  Lateral  motion 
between  the  tarsal  bones  is  sometimes  mistaken  for  lateral  movement  in 
the  ankle-joint.  The  impossibility  of  other  motions  than  flexion  and 
extension  renders  the  occurrence  of  bad  fractures  common  when  falls, 
twists,  or  direct  violence  tend  to  forcibly  evert  or  invert  the  foot  at  the 
ankle-joint.  By  such  mechanism  one  bone  may  be  fractured,  or  one 
malleolus  may  be  torn  off  by  avulsion  through  the  lateral  ligament;  while 
the  other  is  broken  from  the  shaft  by  the  astragalus  within  the  joint  being 
driven  against  its  inner  surface.  Instead  of  involving  the  malleoli  only, 
the  force  mav  fracture  the  tibia  and  fibula  above  the  malleoli,  rupture  the 
ligaments  holding  the  lower  ends  of  these  two  bones  together,  and  even  so 
displace  the  foot  laterally  as  to  drive  one  of  the  bones  through  the  skin. 

The  dissoluticm  of  integrity  of  the  inferior  tibio-fibular  ligamentous 
bond  allows,  by  widening  the  mortise  in  which  the  astragalus  lies,  lateral 
mobility  in  the  joint,  and  suggests  severe  damage  to  the  articulation, 
unless  examination  shows  that  the  line  of  fracture  has  been  limited  to  one 
of  the  malleoli  or  to  the  fibula  above  its  malleolar  extremity.  Occa- 
sionally the  astragalus  has  been  actually  driven  up  between  the  tibia  and 
fibula. 


Fig.  252. 


Fig.  253. 


Diagram  showing  frequent  fracture-lines 
from  forcible  aversion  and  abduction  of  foot. 
(Stimsok.) 


Fracture  of  tibia  and  fibula  at  ankle. 
(Gross.) 


Symptoms. — The  symptoms  in  the  majority  of  cases  are  characteristic 
of  fracture,  though  occasionally  it  is  necessary  to  examine  the  malleoli 
and  fibula  carefully  in  order  to  avoid  calling  the  injury  a  sprain.  Local- 
ized tenderness  and  ecchymosis  will  often  be  determining  symptoms  in 
obscure  fracture  of  these  parts.  "  Sprain-fracture,"  or  sprain  with  detach- 
ment of  a  small  piece  of  bone  from  the  end  of  the  malleolus,  is  not  un- 


FRACTURES    OF    THE    TIBIA    AND    FIBULA. 


439 


common  at  the  inner  malleolus.     The  fracture  of  the  fibula  may  be  two 
and  a  half  inches  above  its  tip. 

In  the  form  of  injury  depicted  in  Fig.  253,  which  is  quite  common, 
the  foot  is  displaced  to  the  outer  side,  the  inner  malleolus  prominent,  the 
sole  of  the  foot  everted,  and  the  heel  apparently  elongated.  There  is 
sometimes  a  groove  on  the  outside  of  the  ankle  at  the  point  where  the 
fibula  has  given  way.  Pain  and  ecchymosis  will  probably  be  found  in 
both  malleolar  regions,  and  lateral  mobility  at  the  ankle-joint  will  be 
detected  if  the  calcaneum  and  astragalus  are  seized  with  one  hand  while 
the  lower  end  of  the  leg  is  grasped  with  the  other.  Motion  in  the  tarsal 
joints  must  not  be  mistaken  for  ankle  motion. 

Fracture  of  the  lower  part  of  the  fibula  can  often  be  detected  by 
placing  the  fingers  behind  the  upper  third  of  its  shaft  and  endeavoring  to 
lift  it  forward.  If  this  causes  pain  about  the  lower  portion  of  the  bone, 
it  is  evident  that  the  fibula  is  fractured  and  movable  at  the  point  of  pain. 
This  test  has  often  been  very  serviceable  to  me  in  obscure  injuries  about 
the  ankle. 

Uncomplicated  fractures  about  the  ankle,  without  much  displacement 
or  with  easily  corrected  displacement,  give  good  results  and  do  not  leave 
any  very  great  final  stiffness.  The  period  of  union  is  about  five  weeks, 
but  it  requires  many  weeks  to  restore  the  mobility  of  the  ankle.  Where 
there  is  great  deformity  and  the  eversion  or  inversion  of  the  foot  cannot 
be  overcome,  permanent  disability  results  from  the  weight  of  the  body 
being  carried  on  a  foot  out  of  proper  line.  The  strain  on  ligaments  and 
bones  in  the  unusual  relations  creates  lameness  and  a  tendency  to  increased 
deviation  from  the  normal  axis.  Open  fractures  in  which  suppuration 
occurs  are  of  serious  prognosis,. because,  when  restitution  of  position  is 
made,  the  external  wound  frequently  does  not  correspond  with  the  point 
of  fracture,  and  decomposing  secretions  are  retained.  Free  incisions  and 
the  introduction  of  drainage-tubes  may  not  only  avert  amputation  but 
save  life.  Ankylosis  is  common  in  bad  fractures  entering  the  joint. 
Such  fractures,  especially,  should  be  treated  with  the  foot  at  a  right  angle 
to  the  leg. 

Fig.  254. 


Method  of  adjusting  the  leg  in  fracture-box. 

Treatment. — There  are  few  fractures  of  the  bones  of  the  leg  that 
cannot  be  properly  treated  in  a  fracture-box,  with  hinged  sides  and  foot- 
piece,  and  appropriate  compresses.  Continuous  horizontal  traction  can 
be  added  to  the  box,  if  the  case  is  such  as  to  demand  it.  Unless  traction 
is  simultaneously  used,  and  it  is  seldom  required,  the  box  should  be  sus- 
pended, because  thus  the  patient  can  have  greater  freedom  of  motion  in 
bed  without  danger  of  displacing  the  fragments. 


440 


DISEASES    AND    INJURIES    OF    BONES. 


The  fracture-box  is  prejiared  by  opening  its  liinged  sides  and  laying 
within  it  a  small  feather  pillow  just  large  enough  to  till  the  space  which 


Fig.  255. 


Fu;.  25fi. 


Suspended  fracture-box,  with  slide  on  cord  by  wliich  box  can  be  raised  or 
lowered.     (Aosf.w.) 

would  exist  between  the  leg  and  the  inner  surface  of  the  box  when  the 
sides  are  closed.     Upon  the  pillow,  close  to  the  footboard,  should  be  placed 

a  ring  of  oakum,  tow,  or  cotton  to  receive  the 
point  of  the  patient's  heel ;  and  over  the  ring 
a  strip  of  bandage  two  feet  long  should  be 
laid.  The  leg  is  to  be  placed  upon  the  middle 
of  the  pillow,  with  the  ankle  bent  at  a  right 
angle  and  the  foot  close  to  the  footboard, 
from  which  it  is  separated  by  only  a  soft  com- 
press. The  foot  is  affixed  to  the  footboard 
by  the  ends  of  the  piece  of  bandage  men- 
tioned being  carried  over  the  top  of  the  foot, 
where  they  are  crossed,  carried  through  the 
slots  in  the  footboard  and  tied  on  its  outside. 
The  next  step  is  to  raise  the  sides  of  the  box, 
by  which  means  the  edges  of  the  pillow  are 
pressed  against  the  broken  limb,  and  to  hold 
them  in  position  by  pieces  of  bandage  drawn 
underneath  the  box  and  tied  over  the  top. 
The  amount  of  pressure  exerted  by  the  sides 
of  the  box,  which  act  as  lateral  splints,  can 


Slide  by  which  fracture-box  is 
raised  and  lowered.  (Aonew.) 


FEACTUEES    OF    THE    TIBIA    AND    FIBULA. 


441 


be  regulated  or  changed  by  tightening  or  loosening  the  encircling  strips  of 
bandage  or  altering  the  thickness  of  the  pillow.  If  any  lateral  deviation 
in  the  line  of  the  leg  is  observed  by  running  the  finger-tip  along  the  crest 
of  the  tibia,  it  can  be  corrected  by  compresses  slipped  between  the  sides 
of  the  box  and  the  pillow  at  the  appropriate  places.  Anterior  or  posterior 
displacement  can  usually  be  overcome  by  elevating  or  depressing  the  heel, 
which  is  done  by  increasing  or  diminishing  the  size  of  the  ring  used  to 
prevent  a  bedsore  on  its  tip. 

Fig.  257 


Elevated  fracture-bos.     (Stimsox.) 


1^0  primary  bandage  should  ever  be  applied  to  the  leg  from  the  toes  to 
the  knee,  as  the  danger  of  gangrene  produced  thereby  is  too  great.  In 
suspending  the  fracture-box,  which  should  always  be  done  except  in  some 
fractures  close  to  the  knee-joint,  and  in  those  which  require  horizontal 
traction  from  the  foot,  cords  should  pass  through  openings  in  the  upper 
part  of  the  sides  of  the  box  and  be  attached  to  a  single  cord  carried  to  a 
pulley  fastened  above  the  bed.  It  is  easy  to  devise  methods  by  which  the 
height  of  the  box  from  the  bed  may  be  changed  to  suit  the  patient.  The 
posterior  end  of  the  box  must  not  be  allowed  to  drag  on  the  bed,  nor 
should  any  position  be  assumed  which  tends  to  permit  motion  or  displace- 
ment at  the  site  of  fracture.  Rotary  displacement  is  a  particularly  un- 
fortunate deformity,  as  permanent  inversion  or  eversion  of  the  toes  is 
unsightly  and  interferes  with  walking.  The  surgeon  should  see  to  it  that 
the  ball  of  the  great  toe,  the  inner  malleolus,  and  the  inner  condyle  of 
the  femur  are  in  the  same  vertical  plane,  or  that  the  great  toe  is  on  a  line 
with  the  inner  edge  of  the  malleolus.  When  muscular  contraction  pre- 
vents complete  reduction  at  the  first  dressing,  fiexing  the  knee  and  ex- 
tending the  foot  will  relax  the  calf  muscles.  Stimson  says  that  compres- 
sion of  the  femoral  artery  for  a  few  minutes  has  induced  for  him 
relaxation  of  the  muscular  spasm.  Subcutaneous  section  of  the  tendon 
of  Achilles  is  rarely  necessary. 

When  the  fracture  is  at  the  upper  part  of  the  leg  the  knee  must  be 
kept  immovable ;  hence  the  fracture-box  should  extend  above  the  knee, 
which  is  to  be  kept  straight  or  slightly  flexed,  according  as  one  or  other 
posture  favors  accurate  adjustment  of  the  fragments.  If  flexion  is  neces- 
sary, a  double  inclined  fracture-box  like  that  used  occasionally  for  frac- 


442  DISEASES    AND    INJURIES    OF    BONES. 

tured  femur  may  be  needed.  It  is  not  easy  to  suspend  this  form  of  box, 
nor  is  it  nece!>sary  ;  but,  with  the  knee  in  a  straight  box,  suspension  is 
readily  accomplished.  The  synovitis,  often  complicating,  should  be 
watched,  and  if  purulent  must  be  treated  by  incisions,  antisepsis,  and 
(Irainatre. 

In  very  oblicjue  fractures  of  the  shaft  continuous  longitudinal  traction 
may  be  needed  to  correct  the  overriding.  This  can  be  attained  by  ele- 
vating the  foot  of  the  bed  as  in  femoral  fractures  and  attaching  a  weight 
to  the  footboard  of  the  box,  after  placing  under  the  box  a  smooth  board 
or  kind  of  railroad  upon  which  it  can  slide  uj)  and  down.  Another 
method  is  to  apply  n  stirrup  to  the  leg,  as  in  fi'actures  of  the  femur,  but 
by  means  of  shorter  adhesive  strips,  and  to  substitute  for  the  fracture-box 
lateral  coaptation  splints  or  sand-bags.  When  the  fracture  is  too  low  to 
give  sufficient  attachment  for  the  plaster,  a  thin  board  may  be  cut  in  the 
shape  of  the  sole  and  attached  to  the  foot  by  strips  of  plaster.  To  this 
footpiece  or  sandal,  cord  and  weight  can  be  fixed,  and  the  lateral  splints 
then  applied  to  the  leg. 

When  the  fibula  alone  is  broken,  when  one  of  the  malleoli  is  split  off, 
and  even  when  the  tibia  itself  is  fractured,  if  the  line  is  transverse  and 
the  fibula  intact,  little  support  is  needed.  Hence  the  fracture-box  may 
be  discontinued  in  a  week,  and  the  ])atient  allowed  to  go  on  crutches  with 
the  circular  gypsum  dressing.  This  should  be  worn  for  about  three 
weeks. 

In  those  cases  of  severe  fracture  at  the  ankle  in  which  the  foot  is  greatly 
everted  or  inverted,  it  is  of  primary  importance  that  the  correct  axis  of 
the  foot  should  be  regained.  Hence  it  is  necessary  to  over-correct  the 
deformity  by  invertinri  the  everted  foot,  or  everting  the  inverted  foot,  and 
keeping  it  so  till  some  degree  of  consolidation  has  occurred,  This  being 
neglected  will  ])ermit  union  to  occur  without  reestablishing  the  close  mor- 
tise between  the  malleoli  in  which  the  astragalus  fits,  ai>d  thereby  will 
leave  a  want  of  solidity  at  the  ankle.  The  projection  backward  of  the 
heel  must  also  be  corrected  by  elevating  it  in  the  fracture-box.  Back- 
ward displacements  can  sometimes  be  well  corrected  by  passing  a  piece  of 
adhesive  plaster  under  the  heel  or  ankle  with  its  adhesive  side  against  the 
skin  and  tacking  its  ends  to  the  upper  and  outer  part  of  the  sides  of  the 
box.  The  fracture-box,  with  the  judicious  use  of  compresses  and  the 
other  adjuvants  mentioned  previously,  will  accomplish  these  indications 
a.s  well,  if  not  better,  than  more  complicated  dressings. 

In  many  fractures  the  great  swelling  will  for  some  days  permit  the  sides 
of  the  box  to  be  only  partially  closed,  hence  the  strips  of  bandage  will 
need  tightening  frequently.  The  box  should  at  first  be  opened  and  the 
leg  examined  once  or  twice  daily.  Afterward  it  may  remain  undisturbed 
for  a  week,  if  no  burning  of  the  heel  or  discomfort  suggests  bedsores  or 
displacement.  The  blebs  frerpiently  seen  on  the  surface,  even  if  contain- 
ing bloody  serum,  are  of  no  importance  as  a  rule,  and  need  no  treatment. 
If  large,  they  may  be  evacuated  with  a  sterile  needle  and  afterward  be 
covered  with  powdered  boric  acid.  They  soon  dry  up.  They  are,  per- 
haps, due  at  times  to  the  unnecessary  swathing  of  the  broken  limb  in 
lead-water  and  laudanum,  or  similar  lotions,  which  are  often  employed 
immediately  after  the  fracture.  Such  applications  are  often  used  with 
the  idea  of  lessening  the  inflammation,  but  their  virtue  in  moderating  the 
deep  inflammation  existing  is  problematical.  Time  is  the  element  re- 
quired. 

At  the  end  of  a  week  in  uncomplicated  fractures  and  after  the  lapse  of 


FRACTUEES    OF    THE    TIBIA    AND    FIBULA. 


443 


from  three  to  five  weeks  in  more  serious  cases,  the  box  should  be  discarded 
and  the  circular  gypsum  dressing  applied  from  the  base  of  the  toes  to  the 
knee  or  above  it.  The  patient  can  then  go  about  on  crutches.  When 
the  fracture  is  at  the  ankle  the  dressing  should  be  made  additionally  firm 
there  by  extra  turns  of  the  bandage.  The  foot  should  in  such  cases  be 
held  in  the  correct  position  for  from  fifteen  to  thirty  minutes,  till  the  gyp- 
sum sets  firmly.  Care  must  be  observed  in  order  that  the  tarsus  itself 
may  be  pressed  over,  and  not  merely  the  anterior  part  of  the  foot.  The 
gypsum  cast  should  be  worn  about  three  weeks  in  all  cases. 

Open  fractures,  not  demanding  immediate  amputation,  are  well  treated 
in  a  fracture  box  after  being  made  thoroughly  aseptic  and  being  sur- 
rounded by  a  large  gauze  dressing.  Drainage  must  be  well  arranged, 
even  if  additional  incisions  are  needed  for  the  purpose.  Free  drainage 
and  frequent  irrigations  are  demanded  if  the  fracture  cannot  be  converted 
into  an  aseptic  wound.     When  union  has  become  pretty  firm,  or  earlier 


Fig.  2.58. 


Van  Wagenen's  sus23en(;lecl  fenestrated  gyjDSum  dressing  for  open  fracture  of  the  leg. 

(Hamilton.) 

if  profuse  discharge  has  ceased,  a  fenestrated  gypsum  dressing  may  be 
substituted  for  the  fracture-box.  The  device  of  Van  Wagenen,  described 
by  Hamilton,  is  especially  nice  for  suspending  such  gypsum  dressings,  and 
it  allows  the  patient  to  turn  on  his  side  and  slide  up  and  down  in  bed. 
Crutches  are  allowed  when  the  fracture  becomes  firm. 

Fractures  of  the  fibula  have  been  discussed  with  those  of  the  tibia ; 
hence  little  further  need  be  said.  Injury  of  the  peroneal  nerve  is  some- 
times an  accompaniment  of  fibular  fracture,  and  is  shown  by  paralysis. 
Localized  pain  and  crepitus,  and  pain  felt  at  the  seat  of  tenderness  when 
the  upper  part  of  the  shaft  is  lifted  as  previously  described,  are  diagnostic 
symptoms,  but  are  not  always  present.  When  the  fracture  is  low  down 
and  accompanied  by  spreading  apart  of  the  malleoli,  lateral  motion  of  the 
astragalus  becomes  possible.  The  upper  end  of  the  fibula  has  occasionally 
been  broken  from  the  shaft  by  violent  contraction  of  the  biceps  muscle. 
In  such  cases  flexion  of  the  knee  to  relax  the  muscle  will  be  a  judicious 
measure  during  treatment.  Union  after  fibular  fracture  occurs  in  three 
or  four  weeks.  When  the  fibula  alone  is  broken  the  fracture-box  can 
be  dispensed  with  in  a  day  or  two  and  the  gypsum  dressing  applied.  In 
some  cases  nothing  more  than  a  bandage  is  needed  from  the  first. 


444  DISEASES    AND    INMURIES    OF    BONES. 


Fracture  of  the  Bones  of  the  Foot. 

These  lesions  are  usually  the  result  of  severe  violence,  which  is  often 
direct ;  hence  many  cases  present,  in  addition  to  the  fracture,  great 
damage  to  the  soft  parts.  Connninuted  and  open  fractures  are,  there- 
fore, common ;  and  amputation  or  excision  of  bone  often  required. 
Very  little  apparatus  is,  as  a  rule,  suthcient  to  immobilize  fractures  of 
the  foot,  because  the  size  and  shape  of  the  bones  and  the  manner  of 
mutual  articulation  does  not  favor  a  wide  range  of  displacing  motion. 
Union  is  to  be  expected  in  uncomjilicated  cases  in  three  or  four  weeks, 
but  ankylosis,  caries,  necrosis  and  prolonged  disability  often  follow  lesions 
of  comj)aratively  slight  significance. 

Fractires  of  the  Tar.>?al  Boxes. — The  astragalus  and  calcaneum 
are  the  only  tarsal  l)ones  whose  fractures  require  special  discussion,  as 
fracture  of  the  astragalus  is  not  infrequently  associated  with  dislocation  of 
the  ankle  and  fracture  of  the  fibula,  or  with  calcaneal  fracture.  ^Marked 
displacement  is  not  very  common  when  the  bone  injury  is  unaccompanied 
by  a  wound  leading  to  the  seat  of  fracture.  The  diagnosis  is  difficult, 
because  the  crepitus,  the  inability  to  bear  the  weight  of  the  trunk  on  the 
foot,  the  pain  and  swelling,  may  be  due  to  fracture  of  the  calcaneum  or 
other  tarsal  bones.  The  treatment  consists  in  reducing  any  apparent 
displacement  and  immobilizing  the  ankle  and  foot  by  a  fracture-box 
or  circular  gypsum  dressiug.  The  foot  should  be  at  a  right  angle  to  the 
leg,  and  its  sole  neither  everted  nor  inverted.  In  closed  fractures,  with 
extreme  displacement  of  fragments,  which  cannot  be  overcome  and  which 
threaten,  by  tension  on  the  integument,  to  produce  ulceration,  excision  of 
the  fragment  nuiy  be  performed  at  once  under  antiseptic  methods. 

In  open  fractures  free  incisions,  counter-openings,  drainage  and  anti- 
septics are  essential  elements  of  success.  Febrile  reaction  and  pain  are 
often  the  surest  indications  that  putrescent  fluids  are  imprisoned.  The 
best  point  for  incision  is  probably  between  the  extensor  tendons  of  the 
great  and  second  toes.  Ankylosis  will  result,  and  hence  the  foot  must  be 
kept  at  a  right  angle  to  the  leg  during  treatment.  The  body  of  the  cal- 
caneum may  be  broken  by  falls,  the  sustentaculum  tali  snapped  cfT  by 
forced  inversion  of  the  foot,  and  the  jiosterior  portion  of  the  calcaneum, 
where  the  tendon  of  Achilles  is  inserted,  pulled  off  by  the  calf  muscles. 
Flatness  of  the  sole,  increased  breadth  of  the  foot  in  the  calcaneal  region, 
approximation  of  the  sole  to  the  malleoli,  and  the  limitation  of  crepitus, 
pain  and  motion  to  the  known  location  of  the  calcaneum  are  the  distin- 
guishing features  of  these  lesions,  which  are  often  obscure  in  diagnosis. 
Fracture  of  the  ledge  of  bone  on  the  inner  and  upper  aspect,  called  the 
sustentaculum  tali,  is  said  to  allow  sinking  of  the  inner  malleolus  and 
eversion  of  the  foot,  and  to  be  attended  by  shortening  of  the  heel,  as  shown 
by  measuring  around  the  back  of  the  heel  from  one  malleolus  to  the  other. 
When  the  posterior  part  of  the  os  calcis  is  detached  by  muscular  contrac- 
tion, the  small  fragment  may  be  displaced  upward  two  or  three  inches. 
The  treatment  comprises  immobilization  in  a  fracture-box  or  circular  gyp- 
sum dressing ;  with  care  to  obtain  correct  position  of  the  foot  when  the 
sustentaculum  tali  has  been  broken,  by  moderate  inversion.  In  muscular 
fracture  of  the  point  of  the  heel,  flexion  of  the  knee  and  extension  of  the 
ankle  will  usually  ])e  required  to  keep  the  fragment  down  in  contact  with 
the  rest  of  the  bone.  A  slipper  attached  by  a  cord  to  a  band  around  the 
lower  third  of  the  thigh  will  accomplish  this.     If  preferred,  an  anterior 


FRACTURE    OF    THE    BONES    OF    THE    FOOT.  445 

splint  may  be  moulded  to  the  anterior  surface  of  the  limb  and  the  dorsum 
of  the  extended  foot. 

Occasionally  the  force  received  tears  out  a  little  scale  of  bone  at  the 
point  of  attachment  of  one  of  the  ligaments.  The  astragalus  is  subject 
to  this  lesion,  which  may  be  termed  a  "  sprain-fracture,"  on  its  posterior 
aspect,  where  the  external  lateral  ligament  is  attached  near  the  groove 
for  the  long  flexor  tendon  of  the  great  toe.  A  similar  lesion  may  occur 
at  the  point  where  the  external  ligament  is  attached  to  the  calcaneum. 

The  metatarsal  bones  most  often  broken  are  those  of  the  great  toe, 
really  by  development  a  phalanx,  and  that  belonging  to  the  little  toe. 
Metatarsal  fractures  show  little  deformity  unless  several  contiguous  bones 
are  broken.  Displacement,  when  it  occurs,  is  apt  to  cause  an  angular 
projection  on  the  dorsum  of  the  foot.  Pressure  of  a  toe  backward  toward 
the  tarsus  will  often,  after  injury,  reveal  fracture  of  the  corresponding 
metatarsal  bone  by  giving  rise  to  pain  at  the  suspicious  spot.  Immobili- 
zation by  a  circular  gypsum  dressing  applied  at  once,  or  by  a  fracture- 
box,  soon  followed  by  the  gypsum  dressing,  is  the  proper  treatment. 
Open  fractures  and  burrowing  of  pus  must  be  met  by  drainage  and  anti- 
septics. If  the  deformity  in  either  closed  or  open  fractures  is  irreducible 
and  of  a  character  to  produce  lameness  or  to  interfere  with  wearing  a 
shoe,  excision  of  the  projecting  portion  of  bone  is  justifiable. 

Fractures  of  the  phalanges  are  often  compound,  and  in  such  cases 
immediate  amputation  may  be  done  more  frequently  than  in  correspond- 
ing injuries  of  the  fingers,  because  the  deformity  and  disability  is  not  as 
important  in  the  foot  as  in  the  hand.  The  toe  in  other  cases  may  be 
made  immovable  by  strips  of  adhesive  plaster  holding  it  to  the  adjoining 
toe,  by  a  gypsum  dressing,  or  by  a  small  pasteboard  splint  bound  to  the 
top  of  the  foot  and  back  of  the  toe  by  adhesive  plaster.  Serious  inflam- 
mation not  infrequently  starts  from  these  insignificant  fractures. 


CHAPTER    XYIII. 


SURGICAL  DISEASES  OF  THE  JOINTS,  CARTILAGES 

LIGAMENTS. 


AND 


CONGENITAL    DICFORMITIES   OF   JOINTS    (CONGENITAL    DISLOCATIONS). 


These  deformities  arise  either  from  iutra-uteriue  traumata  or  from 
nervous  or  other  causes,  which  may  arrest  development  in  portions  of  the 
embryo.  Fortunately,  they  are  of  rare  occurrence,  taking  place  jjrin- 
cipally  at  the  hip;  although  the  jaw,  shoulder,  knee  and  almost  any  joint 
may  be  affected.  They  are  frequently  found  associated  with  such  other 
congenital  defects  as  club-foot,  spina  bifida,  exstrophy  of  the  bladder, 
ventral  hernia  or  encephalocele. 


Fig.  259. 


Fig.  2()i). 


Unilateral  congenital  dislocation  of  the  hip. 
(Kroxleix.) 


Double  congenital  dislocation  of  liij 
(Stimson.) 


Treatment  of  these  dislocations  is  apt  to  prove  unsatisfactory.  Reduc- 
tion should  always  be  attempted,  but  very  rarely,  if  ever,  will  the  effort 
be  crowned  with  success,  as  the  joint  is  more  or  less  defective  in  construc- 
tion or  portions  may  be  entirely  absent.  Most  usually  merely  rudimen- 
tary elements  of    a  joint   exist ;    when    palliative    measures   alone   are 


SYNOVITIS. 


447 


permissible.  All  means  calculated  to  aid  in  the  formation  of  a  false  joint 
should  be  employed,  even  to  dividing  contracted  or  constricting  tissues, 
or  the  neck  of  the  femur.  In  case  of  the  hip-joint  an  apparatus  com- 
bining a  tight  band  around  the  loins  to  force  the  femoral  head  against 
the  ilium,  with  a  perineal  band  to  relieve  upward  pressure  is  to  be 
recommended. 


Synovitis. 

Synovitis  is  an  inflammatory  affection  of  the  lining  membrane  of  a 
joint.  It  occurs  chiefly  in  adults,  and  may  affect  one  or  more  articula- 
tions ;  none  are  exempt ;  but  the  knee,  wrist,  ankle  and  phalanges  are 
most  commonly  involved.  Certain  diatheses,  such  as  the  rheumatic, 
tuberculous,  and  syphilitic,  predispose,  whilst  contusions,  sprains,  disloca- 
tions, neighboring  disease,  and  wounds  act  as  exciting  causes.  A  rigor, 
with  slight  elevation  of  local  and  general  temperature,  pain,  and  creak- 
ing upon  motion,  fixation,  moderate  swelling,  and,  a  little  later,  effusion 
and  fluctuation,  mark  its  advent.  The  synovial  membrane  becomes 
blood-red  in  color  and  swollen,  sheds  its  superficial  cell  layers  and  exudes 
serum,  at  first  limpid  or,  perhaps,  tinged  with  blood,  which  speedily 
becomes  turbid,  or,  in  the  most  intense  varieties,  purulent. 

When  located  in  the  knee-joint,  the  patella  is  floated  from  contact  with 
the  femoral  condyles  when  the  leg  is  extended,  and  when  pressed  upon 
displaces  the  underlying  fluid  and  comes  into  palpable  contact  with  the 
bones  beneath.  Simple  acute  synovitis  is  to  be  treated  by  absolute  rest 
in  an  extended  position,  by  cold  applications,  local  abstraction  of  blood 
by  leeches  or  cups,  counter-irritation  by  blisters,  and,  in  some  cases,  by 
the  application  of  firm  bandages  over  wadding.  Rest  may  be  secured 
either  by  splint  or  extension  apparatus,  but  it  must  not  be  persisted  in 
longer  than  the  more  acute  stage,  .when  cautious  passive  motion  and 
massage  should  be  instituted  to  prevent  adhesions. 


Fig.  26]. 


Chronic  synovitis  of  linee  showing  dilatation  of  synovial  cavity  by  effusion.     (Deuitt.) 

Should  the  affection,  nevertheless,  become  sub-acute  or  chrome,  these 
measures  should  be  coupled  with  more  decided  counter-irritation,  diu- 
retics, cathartics,  and  later,  should  effusion  persist,  with  aseptic  aspiration 
or  washing-out  of  the  cavity. 


448     DISEASES    OF    JOINTS,    CARTILAGES    ANM)    LIGAMENTS. 


Fig.  2fi2. 


Purulent  synovitis  is  a  serious  complication,  recognizable  by  recurring 

rigors,  persistent  high  (103°)  temperature  locally,  constitutional  dif^turb- 

ance,  and  by  hypodermic  aspiration. 

It  is  to  be  treated,  first,  by  aspiration  and  washing-out  of  the  joint, 

and,  this  failing,  by  incision  and  drainage,  or  by  excision  of  the  membrane 

if  that  alone  is  involved. 

Sej)tic  siinovitl-i  is  extremely  resistant  to  treatment,  often  requiring  in 

addition  to  the  usual   constitutional  and  local  measures  such  operative 

procedures  as  will  be  described  under 
arthritis,  and  as  fre(|uently  resulting  in 
ankylosis  or  destruction  of  the  joint.  Its 
cause,  pathology,  diagnosis,  and  treatment 
are  practically  identical  with  the  septic 
form  of  the  latter  aHection,  as  the  process 
occurring  in  the  synovial  membrane  in- 
variably extends  quickly  to  other  struc- 
tures of  the  joint. 

Siiphilitic  synovitis  much  resembles 
simple  acute  and  subacute  synovitis,  but 
is  dependent  upon  and  intercurrent  with 
the  constitutional  disease,  and  promptly 
yields  to  anti-syphilitic  treatment.  It 
may  be  acute  (^r  chronic  ;  is  limited  to 
adults ;  is  symmetrical,  and  usually  occurs 
in  the  knees.  Some  swelling  and  effusion 
accompanies  it,  but  scarcely  any  pain. 
Occasionally  synovial  membranes  undergo 
a  fibroid  change  of  probably  rheumatic 
nature,  and  minute  sessile  or  pedunculated 
whitish  fibroid  bodies  are  developed 
throughout  the  membrane.  These,  during 
movements  of  the  joint,  may  become  separ- 
ated from  their  attachments  and  form  a 
variety  of  "  loose  bodies  "  in  joints.  A 
second  variety  of  this  same  process  exists 
where  the  fibroid  masses  are  developed  in 

the  deeper  layers  of  the  membrane.     Here  they  become  flattened  by  joint 

motion,  and  bear  great  resemblance  to  melon  seeds,  by  which  appellation 

they  are  commonly  known.     These   and   other  fibroid   changes  of  the 

synovial  membrane  occur  in  rheumatic  arthritis. 

Nothing  short  of  excision  of  the  affected  membrane  can  afford  any 

relief  from  these  affections. 

Primary  and  metastatic  neoplasms  of  the  synovial  membranes  rarely 

occur,  but  cannot,  as  a  rule,  be  accurately  diagnosed  save  by  opening  the 

joint.     Effusion  will  usually  be  present. 


Fibroid     hyperplasia    of     synovial 
membrane  of  knee.     (Drlitt.) 


H.EMARTHROSIS. 


Hiemarthrosis  results  from  laceration  of  the  bloodvesstls  of  the  synovial 
membrane.  It  may  occur  in  conjunction  with  synovitis,  or  exist  sepa- 
rately. Blood  quickly  distends  the  cavity  of  a  joint,  but  does  not  clot 
unless  it  has  communication   with   a    fracture.     Marked  fluctuation   is 


ARTHRITIS.  449 

frequent,  but  there  is  usually  no  pain  or  increase  of  heat,  and  upon  hypo- 
dermic aspiration  pure  blood  is  withdrawn.  Small  quantities  of  blood 
thus  effused  into  healthy  joints  is  rapidly  absorbed  under  pressure,  but 
otherwise  must  be  withdrawn  by  aspiration.  Persistent  effusion  after 
injury,  without  pain,  will  almost  invariably  prove  sanguineous.  Haemar- 
throsis  followed  by  degenerative  joint  change  is  common  in  hsemato- 
philics,  when  it  should  not  be  interfered  with  surgically,  unless  its  causa- 
tive condition  has  first  been  effectively  cured. 

Hydrarthrosis,  or  simple  non-inflammatory  infiltration  of  joints,  is 
usually  a  part  of  a  general  oedematous  condition  of  an  extremity  having 
origin  in  heart,  liver,  or  kidney  disease,  or  in  venous  obstruction  or  dis- 
tention. It  can  only  be  relieved  by  removal  of  the  ulterior  cause,  together 
with  elevation  and  elastic  pressure  by  bandages. 


Arthritis. 

When  an  inflammatory  process  has  originated  in  or  been  engrafted 
upon  other  portions  of  a  joint  than  the  synovial  membrane,  it  is  termed 
arthritis.  Practically,  however,  the  distinction  between  synovitis  and 
arthritis  is  frequently  impossible  and  as  often  immaterial  as  regards 
treatment ;  the  synovial  membrane  being  invariably  involved,  either 
primarily,  secondarily,  or  synchronously  with  other  portions  of  the  articu- 
lation. Arthritis  may  involve  a  whole  joint  or  be  limited  to  any  portion 
of  its  extent.  Identical  varieties  are  apt  to  present  at  once  more  severe 
constitutional  and  local  phenomena  than  do  the  corresponding  forms  of 
synovitis,  but  its  development,  on  the  contrary,  occasionally  is  most 
insidious. 

Simple  acute  or  chronic  arthritis  takes  place  as  a  rarity.  Almost  all 
cases  of  arthritis  are  to  be  included  in  the  chronic,  septic,  specific,  and 
neurotic  varieties. 

Acute  suppurative  arthritis  is  a  purulent  inflammation  of  the  entire 
contents  of  a  joint.  It  may  involve  one  or  many  articulations  at  once  or 
consecutively.  The  causes  are  either  contusions  or  wounds  of  the 
joints,  contiguous  inflammation  as  in  epiphysitis,  by  burrowing  of  pus 
from  periostitis  beneath  the  periosteum  into  the  joint,  or  rupture  of  an 
abscess  of  the  bone  head  into  the  articulation.  The  pathology  of  the 
affection  is  simply  that  of  acute  suppurative  inflammation  of  all  the 
elements  of  the  joint ;  the  cartilages  erode  or  necrose,  purulent  or  sanio- 
purulent  effusion  takes  place,  producing  abscess  of  the  joint,  which  subse- 
quently may  rupture  externally  or  penetrate  into  the  surrounding  tissues. 
Finally,  the  joint  may  return  to  a  non-inflammatory  ankylosed  condi- 
tion, or  necrosis  of  the  adjacent  bones  may  take  place.  Taking  the 
knee,  for  example,  pain  increased  by  motion,  chill,  temperature  rising 
to  102°  to  104°,  and  swelling  will  be  the  initial  symptoms.  Fluc- 
tuation, great  swelling  and  oedema,  and  severe  constitutional  depression 
with  high  pulse,  will,  together  with  aseptic  hypodermic  aspiration,  render 
the  diagnosis  certain.  Before  the  diagnosis  of  pus  can  positively  be  made, 
the  joint  must  be  put  at  rest  by  splints,  and  evaporative  lotions,  ice-bag, 
or  irrigations  applied.  When  pus  is  recognizable  (sometimes  when  only 
suspected)  the  joint  should  be  tapped  and  washed  out,  or,  especially  if 
pus  recur,  be  laid  open  and  drained.  Constitutional  support  and  stim- 
ulation, antiperiodics,  and  concentrated  diet  are  of  prime  importance. 
Such  treatment  will  sometimes  save  a  joint  and  preserve  fair  motion,  but 

29 


450     DISEASES    OF    JOINTS,    CARTILAGES    AND    LIGAMENTS 

ankylosis  is  usual.  Later  stages  will  probably  require  excision  or  ampu- 
tation. Klxcept  in  ])yjeniic  cases,  tliese  latter  measures  should,  when 
indicated,  never  be  delayed  if  the  patient  can  withstand  the  shock,  for 
the  rule  is  constant  loss  of  strength  without  recuperation  whilst  the  sup- 
purative process  lasts,  and  the  danger  of  further  constitutional  contami- 
nation is  great. 

Gonorrheal  Arthritis. 

Gouorrhceal  arthritis  is  caused  by  metastasis  of  gonorrheal  pus  from 
the  urethra,  is  almost  limited  to  the  male  sex,  and  involves  as  a  rule  a 
single  large  articulation,  but  may  be  symmetrical,  or  attack  any,  even 
phalangeal  joints.  All  parts  of  the  joint  are  involved.  There  is  great 
])ain,  worse  at  night,  swelling  and  cedema  ;  pressure  and  motion  are  ex- 
tremely painful,  and  grating  may  be  present.  Plastic  exudation,  rather 
than  efi'usion,  takes  place,  which  exudate  commonly  organizes  into  fibrous 
material  which  more  or  less  comj)letely  obliterates  and  ankyloses  the 
joint.  The  urethral  discharge,  which  may  be  either  from  acute  gonor- 
rhoea or  chronic  gleet,  is  not  usually  in  any  way  affected  by  joint  involve- 
ment ;  but  on  the  other  hand,  treatment  of  the  discharge  often  has  a 
marked  beneficial  effect  upon  the  diseased  joint  and  will  prevent  other 
articular  involvement.  Gonorrhoeal  arthritis  is  extremely  resistant  to 
treatment  and  very  apt  to  pursue  a  long  chronic  course.  Absolute  rest, 
leeches,  counter-irritation  by  a  series  of  small  blisters,  morphia  for  pain, 
and  a  liberal  use  of  belladtmna  and  mercurial  ointments  upon  the  joints, 
in  conjunction  with  good  diet  and  hygienic  surroundings,  are  the  most 
beneficial  remedies. 

Tubercular   Arthritis. 

Tubercular  arthritis  usually  takes  origin  from  extension  of  tuberculous 
disease  from  the  contiguous  bone  extremities,  but  may  also  arise  primarily 
in  the  svnovial  membrane.  The  tul)ercle  bacillus  is  invariably  present, 
activelv  causative,  and  diagnostic.  This  form  of  arthritis  is  most  common 
in  childhood  or  youth,  but  may  arise  at  any  age.  In  aged  persons  the 
process  is  apt  to  run  a  rapidly  destructive,  almost  irremediable,  course, 
speedilv  breaking  down  the  joint  and  involving  adjacent  bones.  The 
strumous  or  tubercular  diathesis  invariably  precedes  and  predisposes  to 
joint  infection,  w  hilst  depraved  j^hysical  condition  or  slight  traumata  serve 
as  exciting  causes.  It  frequently  follows  such  diseases  as  measles,  scarla- 
tina, and  typhoid  fever.  The  malady  may  be  limited  to  one  or  several 
joints,  or  be  concomitant  with  or  consecutive  to  tuberculous  lesions  else- 
where. 

Pathology. — Primarily  tubercles  are  deposited  in  the  articular  ex- 
tremities or  membranes  of  the  joint.  Then  follow  irritative  inflamma- 
tion, serous  succeeded  by  purulent  effusion,  distention  and  progressive 
softening  of  the  joint  capsule  and  ligaments,  ending  in  their  rupture  or 
disappearance.  The  membranes  and  cartilages  are  replaced  by  a  fibrous, 
gelatinoid,  yellowish  or  brownish  substance ;  the  bone-ends  are  invaded, 
abscesses  form  and  discharge,  leaving  sinuses  from  which  sequestroe  or 
granular  portions  of  bone  may  be  discharged.  Finally,  by  continuous 
reflex  muscular  contraction,  the  bones  forming  the  articulation  are  drawn 
asunder,  giving  rise  to  great  deformity  and  disability.  The  process  may 
be  arrested  in  the  earlier  stages,  when  the  parts  may  return  to  the  normal 


TUBERCULOUS    ARTHRITIS    OF    SPECIAL    JOIXTS        451 

previous  condition,  or  the  inflammatory  products  may  organize  and  pro- 
duce intra-articular  adhesions  and  more  or  less  ankylosis. 

Symptoms. — Slight  impairment  of  function  is  earlier  or  later  followed 
by  pain  and  swelling.  Pain  may  be  absent  until  later ;  it  is  not  essential, 
or  at  all  characteristic.  No  impaired  function  even  may  be  discernible 
at  first,  save  on  close  examination.  The  temperature  of  the  body  or  part 
may  or  may  not  be  raised.  Soon  the  articulation  assumes  a  white  swollen 
appearance  ;  blue  veins  are  apt  to  course  over  its  surface,  and  upon  palpa- 
tion a  sensation  of  "doughy"  fluctuation  is  apt  to  be  observed,  which, 
later,  will  probably  be  succeeded  by  true  fluctuation,  lateral  move- 
ment, grating,  abscesses,  sinuses,  and  discharge  of  disintegrated  bone 
and  cartilage,  spiculse  or  sequestra,  and  dislocation.  Hectic  will  be 
present  if  the  joints  have  become  infected  through  the  sinuses,  but  not  if 
that  accident  has  been  prevented  by  proper  treatment.  If  purulent  dis- 
charge has  been  of  long  duration,  amyloid  disease  may  complicate  the 
case  and  interfere  with  treatment. 

Treatment. — Absolute  rest  of  the  joint  for  a  long  period,  with  good 
food,  tonics,  iron,  cod  liver  oil,  and  such  measures  as  have  been  sug- 
gested lor  synovitis  and  simple  arthritis,  such  as  cold  applications,  leeches, 
blisters  over  points  of  greatest  pain,  applications  of  iodine,  and  pressure 
by  bandages,  is  the  treatment  for  all  but  the  later  stages.  Should  the 
process  still  continue,  excision  of  the  joint  membranes  and  other  tubercu- 
lous foci  in  the  cavity  (erasion)  is  called  for.  Next  in  order  comes 
excision,  and,  lastly,  if  the  joint  is  utterly  destroyed  or  the  bones  hope- 
lessly involved,  amputation  of  the  extremity. 

Prognosis. — Many  cases  appear  to  recover  perfectly  when  the  disease 
yields  to  minor  measures;  others  preserve  simply  a  stiff  or  ankylosed 
joint.  Excision  and  erasion  are  very  successful,  if  not  left  too  late. 
But  many  live  for  years  with  discharging  sinuses  without  much  discom- 
fort other  than  more  or  less  loss  of  function.  Constitutional  infection  is 
supposed  to  occur  frequently,  if  the  disease  is  not  eradicated.  Tubercular 
meningitis  is  not  rare  at  any  period.  Amyloid  degeneration  of  the  kid- 
neys and  other  organs  sometimes  results  from  continued  purulent  dis- 
charge. Joints  cured  by  minor  measures  are  liable  to  recurrence  upon 
even  trivial  aggravation  or  injury. 


Tuberculous  Arthritis  of  Special  Joints. 
Tuberculosis  of  Vertebral  Articulations  (Spondylitis,  Potfs  Disease). 

Tuberculosis  of  the  vertebral  articulations  conforms,  with  modifications 
due  to  location,  to  the  general  description  of  joint  tuberculosis.  Thus 
situated  the  afifection  is  most  apt  to  develop  between  the  third  and  six- 
teenth years,  but  no  period  of  life,  from  a  few  days  up  to  about  the 
seventieth  year,  is  entirely  exempt.  Any  joint  or  joints  of  the  spine, 
from  the  occipito-atloid  to  the  lumbo-sacral  or  even  inter-coccygeal,  may 
be  affected.  The  lower  dorsal  region  is  most  usually  involved;  then,  in 
order  of  frequency,  come  the  dorso-lumbar,  cervico-dorsal,  cervical, 
lumbar,  lumbo-sacral,  atlo-axoid,  occipito-atloid,  and  inter-coccygeal.  The 
disease  may  develop  simultaneously  or  secondarily  in  two  or  more  distinct 
locations,  or  travel  through  a  considerable  number  of  contiguous  ver- 
tebrae, either  upward  or  downward.  It  may  be  an  entirely  local  disorder, 
a  manifestation  of  general  tuberculosis,  or  itself  may  originate  the  latter. 


452     DISEASES    OF    JOINTS,    CARTILAGES    AND    LIGAMENTS. 

The  course  of  vertebral  tuberculosis  is,  as  a  rule,  slow  ami  chronic,  but 
exceptional  cases  and  those  which  become  infected  through  abscess  open- 
ings may  run  a  very  acute  and  rapid  coui-se. 

A  history  of  traumatic  cause  or  origin  is  almost  always  presented  with 
the  case.  Slight  direct  or  indirect  traumata  are  probably  determining 
and  exciting  causes,  but  the  tuberculous  constitution  must  be  present  to 
render  them  efficient.  Violent  injuries  of  these,  as  of  other  joints,  are 
not  likely  to  be  followed  In'  tuberculosis.  It  may  arise  from  infected 
spinal  wounds. 

PATiiOLO(iY. — As  the  medulla  and  epiphyses  of  the  vertebrne  remain 
soft  and  embryonic  until  long  after  other  cancellar  tissues  have  undergone 
the  permanent  changes  of  adult  bone,  they  are  more  predisposed  to  inflam- 
matory affections  than  other  bones.  Hence,  tubercle  bacilli  find  a  more 
congenial  bone  location  in  the  pulpy  osteo-cartilaginous  or  epiphyseal 
junctions  of  the  vertebne  than  elsewhere.  At  these  points  the  disease  in 
almost  every  case  begins,  although  it  is  possible  that  some  few  originate  in 
the  inter-vertebral  tibro-cartilages  or  synovial  membrane,  except  in  the 
occipito-atloid,  atlo-axoid,  and  inter-coccygeal  varieties,  when  the  disorder 
commences  as  a  tubercular  .synovitis  or  in  the  odontoid  process.  In  every 
case  the  joints  are  (piickly  involved  and  adjacent  cartilages  and  bone  are 
broken  down.  The  destructive  process  is  always  confined  to  the  bodies  of 
the  vertebrae,  while  the  laminte  and  spinous  processes  escape.  At  this  stage, 
before  deformity  takes  place,  the  disease  may  naturally,  or  responding  to 
treatment,  cease,  the  products  organize  or  casefy,  and  no  special  harm  be 
done.  But  much  more  usually  it  progresses ;  the  bodies  of  the  vertebrce  on 
either  side  of  the  first  affected  joint  become  carious  and  crumble  down,  or 
necrose  and  throw  off  se(|uestra? ;  the  super-imposed  portions  of  the  spine 
are  drawn  forward  and  downward  by  gravity  and  action  of  the  abdominal 
muscles,  deformity  results,  abscesses  may  form  and  burrow  in  the  peri-spinal 
sheaths  and  perhaps  infect  new  portions  of  the  column.  If  unretarded,  the 
process  may  continue  until  many  separate  or  contiguous  vertebral  bodies 
are  destroyed,  great  deformity  has  supervened,  and  the  patient  finally 
succumbs  to  suppuration  and  exhaustion.  Unless  the  case  is  complicated 
by  old  lateral  curvature,  the  deformity  is  always  directly  antero-posterior, 
because  the  spinal  arches,  articular  spinous  processes,  and  the  lateral  sup- 
ports of  the  column  are  not  interfered  with.  The  projecting  portions  of 
the  deformity  are  due  to  the  pushed-out  spinous  processes.  Where  the 
seat  of  the  disease  is  situated  in  the  lumbar  region,  deformity  does  not 
appear  or  comes  very  late,  because  the  natural  anterior  curvature  of  the 
spine  at  this  point  must  first  be  overcome  before  angulation  can  become 
evident,  as  well  as  because  of  the  rigidity  and  broad  articular  surfaces  of 
this  region. 

Suppuration  is  not  a  good  index  of  the  disease  ;  it  (abscess)  may  present 
in  advance  of  other  symptoms,  or  not  appear  until  destruction  is  great. 
Some  worst  cases  are  never  complicated  by  its  presence.  Abscess  is  dis- 
covered in  about  twenty-five  per  cent,  of  all  cases,  but  it  occurs  without 
being  fully  demonstrable  in  as  many  more.  At  post-mortems  they  are 
usually  found  concealed  or  sacculated,  and  if  the  case  recover  the  suppura- 
tive products  may  have  organized,  caseated,  or  have  formed  residual  ab- 
scesses. A  variety  of  vertebral  tuberculosis  has  been  recorded  in  which 
the  bodies  of  the  bones  become  honey-combed,  but  do  not  suppurate, 
break  down,  or  produce  deformity. 

Contrary  to  conventional  belief,  angular  deformity  does  not  give  rise  to 
direct  pressure  upon  the  cord,  except  in  rarest  of  instances,  and  when  the 


TUBERCULOUS    ARTHRITIS    OF    SPECIAL    JOINTS.      453 

disease  is  located  at  the  atlo-asoid  junction.  Actually,  there  is  much 
more  than  the  usual  space  for  the  cord  to  pass  through  when  angular 
deformity  exists,  as  then  the  anterior  wall  of  the  canal  is  replaced  by  an 
excavation.  But  such  deformity  by  approximating  the  ribs  may  give  rise 
to  pressure  symptoms  or  destruction  of  the  nerves  emerging  laterally  from 
the  spinal  column.  In  alto-axoid  disease  the  atlas  is  displaced  forward 
upon  the  axis,  the  posterior  arch  of  the  former  compresses  the  cord  more 
and  more  against  the  odontoid  process  of  the  latter,  and  gradual  or  sud- 
den extinction  of  the  functions  of  the  cord,  and  death,  may  result.  The 
paralysis  of  the  more  ordinary  forms  of  the  disease  is  due  to  secondary 
inflammatory  affections  of  the  cord  and  membranes,  and  to  pressure 
from  pent-up  pus,  hemorrhage,  as  from  ulceration  into  the  vertebral 
artery  or  other  vessel,  or  from  a  displaced  sequestrum.  If  the  displace- 
ment or  pressure  be  gradual  in  onset  the  coi'd  will  often  accommodate 
itself  to  it,  and  can  carry  on  its  varied  functions  through  a  very  much 
narrowed  spinal  canal.  Therefore,  it  is  not  strange  that  many  palsies  of 
tubercular  spondylitis  are  often  erratic,  anomalous,  and,  on  occasion,  the 
first  symptom  of  trouble.  Angular  deformity  in  the  cervical  region 
forces  the  chin  upon  the  chest  and  may  produce  dyspnoea,  while  in  the 
dorsal  region  the  same  effect  follows  compression  of  the  thoracic  viscera, 
whence  mechanical  dyspepsia  and  intercostal  neuralgia  may  result. 

The  paralysis  of  vertebral  disease  is  essentially  motor,  and  always  com- 
mences as  such.  Sensory  function  is  last  to  appear  and  first  to  return 
where  improvement  takes  place,  because  the  motor  tracks  being  anterior 
bear  the  brunt  of  the  pressure,  while  the  sensory  are  posterior  and  more 
protected.  Owing  to  sympathetic  connections,  however,  entire  control  of 
the  bladder  and  rectum  sensations  and  functions  is  never  entirely  lost. 

By  continuity,  or  by  abscesses  opening  into  the  spinal  meninges,  tuber- 
culous spinal  or  cerebro-spinal  meningitis  may  be  produced,  but  more 
frequently  the  latter  arises  from  general  miliary  tuberculosis — both  rare 
complications  of  vertebral  tuberculosis. 

When  spinal  abscesses  form  pus  collects  in  front  of  the  affected  vertebrae ; 
upward  progress  is  shut  off  by  the  overhanging,  displaced  vertebrae,  and 
in  other  directions  the  anterior  ligament,  periosteum,  and  pleura  or  peri- 
toneum thicken  and  form  an  abscess  wall  so  that  the  pus,  to  make  its  way 
out,  must  find  exit  on  one  or  other  side  of  the  spine  and  enter  one  or  both 
of  the  sheaths  of  the  psoi  muscles,  and  destroying  the  contained  muscle 
present  in  the  iliac  fossa,  groin,  or  thigh  as  a  psoas  abscess,  or  pass  back- 
ward through  or  external  to  the  quadratus  lumborum,  and  give  rise  to  a 
loin  or  lumbar  abscess. 

Cervical  spinal  abscesses  by  much  the  same  process  point  either  in  the 
pharynx  or  find  their  way  along  the  fasciae  and  muscles  to  some  point  upon 
the  neck.  When  cure  is  established,  after  deformity  has  taken  place, 
true  or  osseous  ankylosis  of  the  affected  vertebrse  takes  place,  inflamma- 
tory products  are  organized,  absorbed,  or  encysted,  the  muscles  relax  their 
vigil,  and  the  cord  becomes  accommodated  to  its  altered  position.  Firm 
ankylosis  is  to  be  desired  in  any  part  of  the  spine.  This  desideratum  usually 
involves  great  deformity  if  much  bone  destruction  has  taken  place,  but 
is  preferable  to  less  deformity  with  the  vertebral  bodies  separated  and  held 
apart  by  slender  bridges  of  bone  which  are  liable  to  fracture  and  danger- 
ous relapse  upon  slight  provocation. 

Symptoms  are  frequently  obscure  at  first  and  extremely  jDalpable  after- 
ward. The  appearance  of  a  boss  of  unnaturally  prominent  spinous  pro- 
cesses may  appear  wdthout  prodromata  and  constitute  the  first  sign.     It  is 


454     DISEASES    OF    JO  I  NTS  ,  C  A  RTI  L  A  GES    AND    LIGAMENTS. 

at  tliis  stage  that  uKist  of  tlie  cases  anionirst  the  poorer  people  are  brought 
to  the  surgeon.  Stitiening  of  the  spine  and  nerve  syni])toins  usually  long 
precede  recognizable  det'orniity.  Pain  will  usually  attract  the  person's 
attention  and  may  be  mistaken  for  colic,  muscular  cramps,  dyspepsia, 
rheumatism,  neuralgia,  or  "growing  pains."  It  is  aggravated  by  motion 
or  concussion  of  the  spine,  as  in  riding  in  a  carriage,  over  crossings  in  a 
street  car,  or  by  missing  a  step ;  is  always  referred  to  the  same  locations 
and  is  relieved  by  rest.  It  is  usually  complained  of  as  intercostal,  sub- 
sternal, sciatic,  or  as  headache  of  the  occipital  distribution  when  the  dis- 
ease is  located  in  the  cervical  spine.  Some  local  pain  or  tenderness  may 
be  present,  but  this  is  usually  dull,  whilst  the  referred  pains  are  apt  to  be 
sharp.  Before  actual  pain  develops  various  minor  sensations,  as  tingling, 
burning,  formication  and  itching,  may  be  present.  It  may  be  referred  to 
the  hip,  which,  accompanied  with  spine  lameness  or  alteration  of  gait,  may 
cause  error  in  diagnosis.  The  sensation  as  of  a  cord  tied  tight  around 
the  chest  or  abdomen,  and  spasmodic  abdominal  attacks  with  accompany- 
ing or  subse(iuent  flatulent  distention,  are  not  uncommon  syniptoms.  Pain 
and  muscular  tension  can  usually  be  relieved  at  once  by  longitudinal  ex- 
tension or  by  bending  the  spine  in  a  direction  contrary  to  the  angle  of 
deformity,  as  by  a  hand  ])laced  under  the  back  and  the  patient  thereby 
partially  raised.  In  rare  instances,  however,  they  may  thus  be  aggravated. 
Elevated  temperature  may  be  a  prominent  or  an  absent  feature  of  the 
case.  When  acute  it  rises  to  101°  or  102^.  If  abscesses  become  infected 
it  may  rise  higher,  and  then  become  of  hectic  type.  A  high  terapei'ature, 
except  at  first,  or  upon  abscess  infection,  will  indicate  grave  complications. 
Paralysis  or  other  severe  nerve  symptoms  may  occur  at  any  stage,  as  also 
may  those  of  spinal  inflammation,  cerebrospinal  meningitis,  general  miliary 
tuberculosis,  phthisis,  hip  disease,  empyema,  and  peritonitis. 

At  once,  or  after  a  lapse  of  months,  or  even  years,  prominence  of  the 
spines  of  the  affected  vertebrie  and  angular  deformity  appear  in  varying 
degree.  So,  also,  is  it  the  case  with  abscesses;  they  may  present  early, 
late,  not  at  all.  Anesthesia  may  be  required  for  their  diagnosis  if  deeply 
situated.  Very  late  loss  of  motion,  then  sensation,  and  finally  contrac- 
tion of  leg-muscles,  bedsores,  or  amyloid  degeneration  of  viscera  may 
supervene  ;  the  muscles  waste,  and  the  patient  becomes  excessively  blood- 
less, pallid,  and  of  aged  appearance,  even  if  very  young. 

Certain  special  symptoms  pertain  to  atlo-axoid  and  occipito-atloid  dis- 
ease. There  may  be  spasm  of  the  sterno-mastoid  or  choreic  movements 
of  the  neck  muscles  or  neuralgia  or  paralysis  of  the  brachial  plexus,  all 
of  which  are  increased  by  nodding  rather  than  by  rotation,  and  relieved 
by  occipital  extension.  Laryngeal  cough,  or  stridor,  difficulty  in  respi- 
ration, deglutition,  or  phonation  may  be  present.  Sometimes  grating  or 
crepitus  can  be  developed  by  motion.  The  head  is  stiff,  thrown  forward 
or  to  either  side,  the  chin  forced  upon  the  sternum,  the  neck  appears 
shortened,  and  the  spine  of  the  axis  is  extremely  prominent.  Karely  the 
head  in  addition  to  being  thrown  forward  is  turned  upward  by  spasm  of 
the  posterior  neck  muscles.  The  head  is  held  in  the  hands  when  the 
disease  is  extensive ;  there  is  danger  in  any  movement ;  the  patient  is 
apprehensive  of  sudden  death  and  cannot  lie  down  or  lean  forward. 
There  is  constant  danger,  in  extreme  cases,  of  sudden  dislocation  or 
fracture,  pressure  upon  the  cord  and  instant  death.  Abscesses  of  this 
region  usually  point  in  the  pharynx  or  upon  the  neck. 

Diagnosis. — With  this  end  in  view  the  patient  should  be  stripped  naked 
in  a  warm  room  and  stood  before,  or  laid  across  the  knees  of  the  surgeon. 


TUBERCULOUS    ARTHRITIS    OF    SPECIAL    JOINTS.      455 


Fig.  263. 


All  cases  wherein  there  is  any  possibility  that  disease  of  the  spine  may  be 
present,  to  account  for  distant  or  obscure  symptoms,  should  be  thus 
examined. 

Spinal  pains  can  best  be  'elicited  by  motion  of  the  column  and  pressure 
in  its  axial  direction.  Percussion,  applications  of  electricity,  heat  or 
cold,  are  most  unreliable. 

Muscular  symptoms  are,  perhaps,  most  important.  Almost  as  soon  as 
disease  commences  the  erector-spinse  muscles  involuntarily  assume  the  sup- 
port of  the  column  to  prevent  movement  of,  or  pressure  upon,  the  diseased 
part.  This  gives  rise  to  characteristic  postures  and  modified  movements, 
recognition  of  which  is  most  to  be  desired,  for  treatment  instituted  at  this 
stage  is  highly  successful  and  prophylactic. 

No  skill  is  required  to  diagnose  later  stages  when  deformity  has  taken 
place,  nor  will  treatment  then  avail  for  much.  The  characteristic  posture 
is  one  of  caution  and  apprehension. 
The  child  tires  of  play,  lies  about,  or 
seeks  support ;  is  easily  fatigued.  Com- 
plains, perhaps,  of  local  or  referred 
pains  or  other  sensations,  is  clumsy  in 
walking,  or  struts  or  shuffles  along 
without  elasticity.  He  is  afraid  of 
jarring,  does  not  jump  ;  turns  rather 
than  look  around,  and  in  every  way, 
quite  involuntary,  as  a  rule,  at  first, 
saves  the  spine  from  motion  or  con- 
cussion. The  head  is  thrown  back, 
the  shoulders  elevated  by  the  trapezii, 
the  arms  hang  at  the  sides,  and  the 
toes  turn  out.  All  movements  are 
guarded.  If  asked  to  pick  up  an  ob- 
ject from  the  floor  he  rests  a  hand 
upon  the  corresponding  thigh  and 
bends  the  knees  until  the  free  hand 
reaches  the  object,  or  he  may  kneel 
outright.  He  may  continually  hold 
his  head  in  his  hands,  and  phonation, 
respiration,  or  deglutition  may  be  in- 
terfered with  if  the  aflfection  be  cer- 
vical. 

Even   slight  stiffness   of  the  spine   (Smith.) 
can   be  made  evident   by   the  above 
and  other  gymnastic  performances,  which  the  surgeon's  ingenuity  will 
supply. 

Vertebral  tuberculosis  must  be  differentially  diagnosed  from  rheuma- 
tism ;  neuralgia ;  affections  of  the  cord  and  membranes,  as  myelitis,  and 
meningitis;  sprains;  tuberculosis  of  the  hip;  abscess,  and  other  affections 
of  the  liver  and  kidney ;  perityphlitis,  aneurism,  and  tumors  of,  or  press- 
ing upon,  the  vertebrae.  The  last-mentioned  diseases  may  exactly  present 
the  usual  symptoms  of  spinal  disease,  even  to  the  characteristic  deformity 
by  pressure  absorption  of  the  vertebral  bodies,  and  cannot  be  positively 
defined  therefrom  until  late.  Happily,  these  conditions  are  very  uncom- 
mon. 

Tuberculosis  of  the  vertebral  joints  may  become  engrafted  upon  a  spine 
already  affected  with  lateral  curvature,  when  some  symptoms  may  be 


Early  dorsal  vertebral  tubereulosis; 
typical  posture  in  stooping;  child  cannot 
bend  spine  in  picking  up  object,  and  sup- 
ports   her   weight    by   hand    on    knee. 


456     DISEASES    OF    JOINTS,   CARTILAGES    AND    LIGAMENTS. 

decidedly  moditiod.  I  concede  the  possibility,  indeed  the  belief,  that 
other  than  tuberculous  forms  of  intianiniation  of  the  spinal  joints  and 
])ones  take  place,  but  think  (as  treatment  would,  in  all  cases,  be  identical 
and  so  little  is  known  of  the  other  varieties)  to  prevent  confusion  by  omit- 
ting their  description. 

Treatmknt  is  of  greatest  value  in  the  earlier  stages,  when  the  disease 
may  often  be  entirely  checked.  The  great  indications  are  to  build  up  the 
vital  powers  and  to  secure  local  rest.  The  former  is  to  be  attained  by 
attention  to  the  hygienic  surroundings  and  diet  of  the  ])atient,  and  by  the 
administration  of  such  agents  as  cod-liver  oil,  iron,  iodide  of  potassium 
or  mercury,  hypophosphites,  strychnia,  and,  perhajis,  phosphorus.  A  little 
l)randy  can  often  l)e  added  to  the  diet  with  advantage.  Removal  to  sea 
or  country  air  will  usually  make  marvellous  changes  for  the  better.  Even 
if  it  is  necessary  for  the  patient  to  remain  in  bed,  he  should  be  placed  upon 
a  hard  hair  mattress  cot,  which  can  be  carried  into  the  yard,  to  the  roof, 
or  to  another  room.  Massage,  electricity,  and  douching  must  not  be 
neglected.  From  the  first  appearance  of  symptoms  until  consolidation 
has  well  advanced  (most  certainly  while  any  acute  symptoms  last)  the 
patient  should  be  kept  in  bed,  and,  as  much  as  possible,  motionless  upon 
his  back.  While  symptoms  are  very  acute  sand-bags  may  be  placed 
upon  each  side  of  his  body.     Even  greater  repose  can  be  secured  when 


Fig.  264. 


Extension  in  the  recumbent  jjosture.     (  Wykth,  after  Reeves.) 

indicated  by  applying  extension  to  the  neck  and  elevating  the  head  of 
the  bed  ;  by  its  application  to  the  legs  and  elevating  the  foot  of  the  bed, 
or  by  the  conjoint  application  of  both  methods.  It  is  also  well  to  place 
a  small  pillow  under  the  angle  of  deformity,  or  to  sustain  that  portion  of 
the  body  in  a  sort  of  sling,  after  the  manner  of  Reeves.  I  do  not  wish, 
however,  by  this  advice  to  be  construed  as  endorsing  methods  which  tend 
to  correct  forcibly  the  deformity,  which,  in  my  opinion,  are  ill-advised  and 
contrary  to  the  teachings  of  pathology.  Neck  extension  is  especially 
called  for  in  cervical  disease.  The  object  of  treatment  by  posture  and 
moderate  extension  is  to  relieve  muscle  tension,  and  pressure  upon  the 
affected  vertebrte  ;  by  which  are  secured  consolidation  with  least  deformity, 
and  comfort  to  the  patient  meanwhile.  Desperate  cases,  where  bedsores 
are  threatened,  must  be  placed  upon  an  air-  or  water-bed. 

When  acute  symptoms  have  subsided,  the  patient  may  be  allowed  to 
get  up  and  go  about  in  a  brace.  Where  limited  circumstances  prohibit 
more  expensive  apparatus,  the  plaster  jacket,  while  not  so  light,  conve- 
nient, or  comfortable  as  other  apparatus,  yet  answers  every  purpose  of 
treatment. 


For  its  application  the  patient  should  be  stripped  to  beneath  the  hips, 
or  entirely,  and  a  close-fitting  woollen  shirt,  extending  below  the  trochanters 
and  provided  with  shoulder-straps,  put  on.  He  is  then  raised  in  a  sus- 
pension apparatus  until  he  is   comfortably  resting  upon  the  great  toes. 


Fig.  265. 


Suspension  by  means  of  tripod  for  application  of  jacket  for  spinal  disease. 

Now,  while  he  grasps  the  suspension  rod  with  his  hands,  moistened  crino- 
line bandages,  well  impregnated  with  plaster-of- Paris,  are  evenly  wound 
about  the  trunk  from  just  below  the  trochanters  to  the  axillae.  Any 
inequalities  are  smoothed  over  by  the  hand  or  a  little  moist  plaster  rubbed 
into  them.  A  folded  towel  should  be  placed  over  the  lower  abdomen  to 
allow  for  subsequent  distention  of  the  stomach  by  food,  but  this  can  be 
dispensed  with  if  the  patient  has  recently  partaken  of  a  meal.  If  the 
patient  is  a  female,  that  portion  of  the  jacket  in  the  interval  between  the 
breasts  should  be  well  moulded  in  before  the  plaster  sets.  As  soon  as  the 
plaster  has  become  firm,  it  is  cut  vertically  in  the  median  line  in  front  and 
carefully  sprung  off.     It  is  then  trimmed  along  the  borders  with  chamois 


458     DISEASES    OF    JOINTS,    CARTILAf^ES    AND    LIGAMENTS. 


.skin,  somewhat  pjulded  in  the  axilhc,  and  lacing  eyelets  placed  along  the 
cut  edges. 


Fir,.  2t)r.. 


Sliears  for  cutting  gj'psuin  bandages  and  jacket?. 

If  the  vertebral  prominence  is  sharp  or  irritable,  a  ring  of  wool  should 
be  placed  about  it  before  the  bandages  are  applied,  or  a  fenestrum  may  be 
cut  in  the  jacket  and  its  edges  padded.  Or,  wlien  even  this  much  cannot 
be  afforded,  jackets  may  be  applied  every  few  weeks  and  allowed  to  re- 
main uncut  until  it  is  time  to  apply  a  new  one;  but,  in  so  doing,  great 
care  must  be  observed  in  young  children  to  see  that  pressure  sores  do  not 

(t  Fig.  267.  b 


a.  Leather  jacket  with  jur\'-mast.     b.  Same,  applied. 

develop  and  that  vermin  do  not  find  lodgement.  Where  circumstances 
permit,  it  is  much  preferable  to  use  the  plaster  jacket  simply  as  a  mould 
in  which  is  cast  a  plaster  model  of  the  body,  around  which  is  accurately 
fitted  a  leather  or  felt  jacket,  which  is  subsequently  trimmed,  fitted  with 
eyelets,  and  extensively  perforated. 


TUBERCULOUS    ARTHRITIS    OF    SPECIAL    JOINTS, 


459 


The  above  will  answer  perfectly  for  all  diseases  located  below  the  upper 
dorsal  region.  Otherwise  a  supporting  head  gear  must  be  fitted  to  the 
jacket.  This  is  done  by  either  fastening  the  head-piece  between  the  folds 
of  bandages  or  by  subsequently  riveting  it  upon  the  completed  brace. 

For  disease  of  the  cervical  spine  and  of  the 
occipito-atloid  region,  the  "jury-mast"  head- 
gear will  not  always  afford  sufficient  security. 
Then  some  such  device  as  the  leather  collar  is 
more  appropriate,  and  the  jacket  is  dispensed 
with,  but  such  cases  had  best  remain  in  bed 
until  firm  ankylosis  has  taken  place.  Remov- 
able jackets  need  not  be  worn  in  bed.  If  the 
spine  straightens  out,  or  if  the  proportions  of 


Fig.  2ri0. 


Head  support  for  spinal 
tuberculosis. 


Breast-j)Iate  and  collar  for  cervical  or  high  dorsal 
caries.     (Owen.) 


Fig.  270. 


the  patient  materially  change,  a  new  apparatus  must  be,  in  the  same 
manner,  applied.  Nothing  but  the  shirt,  or  shirt  and  chemise,  must  be 
worn  beneath  the  jacket,  and  it  is  well 
for  each  patient  to  have  a  suspension 
apparatus  and  put  on  his  brace  while 
the  spine  is  extended.  If  the  child  is 
continually  kept  in  the  admirable  sus- 
pension chair  of  Dr.  Meigs-Case  w'hen 
out  of  bed,  no  jacket  will  be  required. 

Operations  intended  to  remove  the 
diseased  portions  of  the  diseased  ver- 
tebrae, or  to  afford  direct  drainage,  have 
been  performed,  but  enough  is  not  yet 
known. of  these  measures  to  justify  either 
criticism  or  endorsement. 

Treatment  of  Abscesses. — When- 
ever a  palpable  abscess  is  accompanied 
with  pain,  fever,  or  other  marked  local 
or  constitutional  signs,  it  should  be 
opened  forthwith.  But  if  it  do  not 
incommode  the  patient,  it  need  not  be 
interfered  with  until  it  shows  some  ten- 
dency to  point  or  open.  Abscesses  should 

never  be  allowed  to  open   spontaneously,        Suspension  chair  of  Dr.  Meigs-Case 


400     DISEASES    OF    JOINTS,   CARTILAGES    AND    LIGAMENTS. 

for  fear  of  infection.  .Such  infection  usually  gives  tenfold  impetus  to  the 
disease,  and  may  cause  speedy  death  by  suppurative  exhaustion.  In 
opening  abscesses,  al)solute  antiseptic  ])recauti()ns  should  be  taken.  Free 
incision  is  made,  the  sac  washed  out  with  1  :  1000  bichloride  solution, 
freely  curetted  as  far  as  p().«sible,  again  washed  out  and  the  incision 
sutured,  leaving  in  a  large  drain.  A  large  dressing  should  then  be  ap- 
plied and  renewed,  and  the  sac  re-washed  upon  the  slightest  indication 
therefor.     Thus  treated,  their  opening  causes  none  but  beneficial  results. 

Psoas  abscesses,  if  detected  in  time,  can  be  more  easily  dealt  with  by 
cutting  down  upon  the  sac  above  Poupart's  ligament. 

Prognosis. — Tubercular  spondylitis  is  rarely  fiital  under  ordinary  cir- 
cumstances. Prognosis  depends  upon  the  age  of  the  patient,  the  duration 
and  location  of  the  disease,  and  whether  abscesses  have  formed  or  have 
become  infected.  High  cervical  disease  is  always  dangerous,  occasionally 
suddenlv  fatal. 


Tuberculosis  of  the  Sacro-iliac  Articulation. 

This  seat  of  tuberculosis  is  not  uncommon,  and  often,  especially  during 
early  stages,  is  confounded  with  sciatica  and  hip-joint  disease.  It  occurs 
rarely  in  children  ;  between  the  ages  of  fifteen  and  thirty-five  it  is  most 
common.  The  causes  are  either  local  traumata  or  extension  from  the 
acetabulum  or  from  iliac  or  hip-joint  abscesses  burrowing  into  the  articu- 
lation. 

The  symptoms  are  pain,  local  and  radiating,  tenderness  upon  pressure 
or  motion,  especially  when  pressure  is  made  upon  the  iliac  crests,  perhaps 
interference  with  or  painful  defecation  or  urination,  and,  rarely,  njdema  of 
the  corresponding  limb  from  swelling  pressure  upon  the  iliac  vein.  The 
body  is  inclined  to  the  sound  side  to  secure  absence  of  pressure,  and  exten- 
sion by  weight  of  the  sound  limb.  Swelling  occurs  early,  but  does  not 
shift  from  over  the  line  of  articulation  or  obliterate  the  gluteal  fold,  but 
later,  especially  when  abscess  forms,  the  tumefaction  may  extend  to  and 
change  the  buttock  contour.  Always  there  is  wasting  of  the  gluteal 
muscles  and  loss  of  power  in  the  limb.  Apparent  lengthening  of  the 
limb  is  due  to  dropping  the  pelvis  to  secure  ease;  the  foot  is  everted. 
Abscess  may  subsequently  form  and  point  locally,  or  discharge  into  the 
pelvis  or  its  contained  organs,  through  the  sciatic  foramen  into  the  but- 
tock, via  the  levator  ani  and  obturator  fascia  into  the  ischio-rectal  fossa, 
or  upon  the  inside  aspect  of  the  thigh. 

The  afl^ection  must  be  diflferentiated  from  spinal  or  innominate  caries, 
hip  disease,  and  sciatica. 

Treatment  of  the  early  stages  should  comprise  strict  rest,  extension, 
proper  diet;  plus  blisters,  cautery,  or  iodine  paintings  locally.  Later,  if 
all  goes  well,  a  hip  case  or  splint,  or  crutches  may  be  allowed.  If  by 
these  means  progress  of  the  disease  is  pot  quickly  arrested,  and  more  par- 
ticularly if  abscess  supervene,  the  joint  must  at  once  be  laid  open  by  in- 
cision of  its  own  direction  and  length,  and  the  diseased  portions  of  the 
membrane  or  bone  scraped  or  chiselled  away.  Following  this  the  wound 
should  be  kept  well  packed  with  antiseptic  materials  until  it  heals.  Often 
all  that  we  can  do  will  not  prevent  the  patient  finally  dying  from  exhaus- 
tion. 


TUBERCULOSIS    OF    HIP-JOINT.  461 

Titberciilosis  of  Hip-joint. 

Tuberculosis  of  the  hip-joint  is  a  disease  very  frequently  met  with. 
Two-thirds  of  all  cases  are  under  sixteen  years  of  age  ;  males  are  most 
often  affected.  It  may  attack  one  hip  or  both  either  synchronously  or  at 
different  times. 

Causes  are,  in  order  of  frequency  :  injury,  spontaneous,  and  auto- 
infection  from  other  organs  or  tissues. 

Pathology. — -The  inflammation  may  begin  as  a  tubercular  epiphysitis 
of  the  head  of  the  femur,  and,  the  epiphyseal  junction  being  entirely  within 
the  joint-capsule,  thence  quickly  spread  to  the  other  articular  structures. 
Or  it  may  take  onset  upon  the  acetabulum  floor  iu  the  lines  of  union 
of  the  three  segments  of  the  ilium  ;  in  the  synovial  membrane  ;  or,  possibly, 
in  the  ligamentum  teres.  But  most  usually  the  disorder  is  supposed  to 
originate  in  the  osteo-cartilaginous  junction  of  the  femoral  head. 

According  to  the  constitution  of  the  patient  the  case  will  run  either 
an  acute  or  chronic  course.  If  acute,  profuse  suppuration  and  breaking 
down  of  the  contents  of  the  joint  and  necrosis  of  the  neighboring  bones 
take  place.  Or,  if  epiphysitis  has  taken  place,  the  head  of  the  femur  may 
become  entirely  detached  into  the  joint.  The  worst  forms  are  those  where 
the  tuberculous  process  is  transmitted  along  the  bone  shafts,  through  the 
bottom  of  the  cotyloid  cavity  into  the  pelvic  bones  or  their  neighboring 
organs,  or  into  the  blood  current  as  miliary  tuberculosis. 

In  the  chronic  variety,  on  the  other  hand,  the  disease  is  persistent;  pus 
is  not  formed,  or  only  slowly,  the  effused  materials  are  plastic,  become 
firm  and,  in  time,  give  rise  to  fibrous,  rarely  osseous,  ankylosis. 

In  either  case,  but  especially  the  former,  destruction  of  the  joint  plus 
continuous  muscular  action  may  dislocate  the  altered  head  or  neck  of  the 
femur  upon  the  dorsum  ilii  and  give  rise  to  great  deformity. 

Symptoms. — Often  before  positive  symptoms  develop,  the  child  is  noticed 
to  exhibit  lassitude,  to  tire  easily  of  play,  become  pallid,  sleep  uneasily, 
lose  strength,  and,  perhaps,  be  feverish.  He  eases  the  affected  limb  in 
exercise,  play  or  standing,  and,  possibly,  may  complain  of  what  are  vul- 
garly taken  for  "  growing  pains  "  in  the  knee,  thigh,  or  hip.  Great  atten- 
tion should  be  paid  to  these  conditions,  as  diagnosis  at  this  stage  is  of  vital 
importance.  Yet,  no  one  sign  can  be  depended  upon  more  than  to  centre 
attention  upon  the  parts,  and,  perhaps,  indicate  precautionary  treatment 
until  others  develop. 

Stiffening  will  be  the  first  positive  symptom  and  give  rise  to  lameness 
and  a  characteristic  standing  posture,  where,  leaning  a  little  forward,  all 
weight  is  thrown  upon  the  sound  limb,  while  the  other  is  advanced,  slightly 
flexed,  abducted,  and  rotated  outward.  Stiffening  of  the  joint  in  varying 
degrees  of  flexion,  at  first  by  muscle  tension  to  prevent  motion,  and  later 
by  joint  changes,  is  present  in  all  stages  of  the  disease.  Even  in  the 
slightest  amount  it  can  be  recognized  by  placing  the  child  flat  upon  a 
table,  and  upon  attempting  to  straighten  out  the  affected  leg,  the  vertebrte 
become  arched  forward  by  tension  upon  the  psoas  and  iliac  muscles  and 
the  hand  can  readily  be  carried  beneath.  When  the  sound  limb,  which, 
to  gain  the  confidence  of  the  child,  should  first  be  examined,  is  so  manipu- 
lated, no  change  in  the  back  takes  place.  This  involuntary  muscular 
tension,  which  is  shared  in  by  all  the  anterior  muscles  of  the  thigh,  is  to 
protect  the  joint  from  motion  and  consequent  production  of  pain.  The 
degrees  of  flexion,  abduction,  and  rotation,  indicate  that  position  of  the 
joint  which  gives  most  room  to  accommodate  the  effusion  always  present 


402     DISEASES    OF    JOINTS,   CARTILAGES    AND    LIGAMENTS. 

ill  the  joint ;  later,  flexion  may  depend  upon  excessive  muscle  contrac- 
tion. Impaired  motion  of  the  joint  is  amongst  the  most  valuable  of  early 
signs.  If  motion  is  unimpaired,  it  is  aluKJSt  conclusive  evidence  that  no 
hip  disease  is  present.     Interference  with  extension  and  flexion  may  be 

Fig.  271. 


Test  for  fixation  of  hi|)-Joint — position  of  leg  when  spine  is  straiglit.     (Smith.) 

Fig.  272. 

/ 


Curvature  of  spine  when  leg  is  extended.     (Smith.) 

caused  by  spinal  disease,  but  rotation  (the  crucial  test)  is  only  impeded 
by  hip-joint  involvement.  To  apply  the  test,  flex  the  thigh  to  an  angle 
of  120  degrees  and  then  attempt  rotation. 

All  manipulations  should  be  most  gentle,  cause  little  or  no  pain,  and, 
except  to  diagnose  very  late  complications,  anaesthesia  should  never  be 
employed,  as  it  will  relax  all  muscles  and  thus  defeat  our  object. 

Pain,  while  usually  present  in  some  degree  locallv,  yet  is  most  com- 
plained of  about  the  knee,  over  the  patella,  or  upon  the  inner  side  of  the 
thigh.  Especially  is  it  referred  to  these  parts  when  the  disease  is  located 
in  the  femoral  head.  The  mechanism  of  this  referred  pain  is  not  clearly 
understood,  but,  undoubtedly,  the  proximity  of  branches  of  the  obturator 
distribution  in  part  explains  it.  There  are  no  referred  pains  at  first,  when 
the  process  i)rimarily  involves  the  synovial  membrane,  but  local  pain 
from  capsule  tension  is  severe  and  constant.  When  the  capsule  is  tense 
there  is  much  tenderness  in  the  groin  and  above  the  great  trochanter. 
Sudden  ceasing  of  long-continued  severe  pain  indicates  that  the  capsule 
has  given  away  and  the  fluid  joint  contents  have  escaped  into  the  sur- 
rounding tissues.  Night  starting  and  sudden  cryings  out  (ostitic  cry) 
during  sleep  or  waking  moments  are  common,  being  due  to  the  muscles 
having,  during  sleep,  relaxed  their  vigil  only  to  assume  rigidity  again 
suddenly  and  painfully  as  the  child  awakens.  Pain,  both  locally  and 
referred,  is  increased  by  inward  pressure  upon  the  great  trochanter. 
Pounding  the  heel  or  flexed  knee  is  a  very  crude  and  valueless  method 
of  developing  hip  tenderness.  Patients  suffering  acutely  from  hip-joint 
distention  occasionally  can  gain  more  relaxation  of  capsule  and  quietude, 
hence  comfort,  by  cro.ssiug  the  knee  over  the  sound  thigh  or  by  hugging 
it  upon  the  abdomen  or  chest. 

Sivelling  is  early  and  most  noticeably  developed  in  the  .synovial  variety. 


TUBERCULOSIS    OF     HIP-JOINT, 


463 


Fig.  273. 


Diagram  showing 
flattening  of  buttock 
and  lowered  position 
of  gluteal  crease  on 
diseased  side. 


Great  heat  and  redness  do  not,  as  a  rule,  accompany  it,  except  in  acute 
tuberculous  abscesses  of  the  joint  or  surroundings,  but  more  or  less  local 
rise  of  temperature  is  present.  Swelling  is  most  apparent  in  the  groin, 
where  the  inguinal  glands  will  be  very  prominent,  about  the  great  tro- 
chanter, and,  in  a  minor  degree,  in  the  buttock,  and  about  the  joint 
generally. 

Muscular  Wasting  or  Atrophy  early  sets  in  and  involves  the  joint  sur- 
roundings and  the  entire  limb.  The  proportions  (even  length,  as  the 
bones  participate)  of  an  affected  limb  will  never 
again  equal  those  of  its  fellow.  Comparative  meas- 
urements of  the  calves  and  thighs  will  demonstrate 
the  presence  and  amount  of  atrophy.  Wasting  of 
the  gluteal  muscles,  together  with  the  swelling  in 
that  region,  flattens  and  broadens  the  buttock,  shal- 
lows or  obliterates  the  natural  crease  or  fold  and 
creates  a  deviation  of  the  internatal  line  toward  the 
sound  side.  To  observe  gluteal  changes  the  patient 
is  stood  naked  on  a  table,  his  back  to  the  surgeon. 

Compensating  Postures.  —  Continued  hip  disease 
from  muscular  tension  in  time  gives  rise  to  a  lateral 
curvature  of  the  lumbar  spine  and  compensating 
curve  in  the  dorsal  region.  This,  with  abduction  of 
the  thigh,  makes  the  leg  appear  lengthened.  But 
until  great  bony  destruction,  or  actual  dislocation 
of  the  joint  occurs,  changes  in  length  of  the  limbs 
do  not  occur,  except  rarely,  when  great  distention 
of  the  capsule  forces  the  femur  away  from  the  ace- 
tabulum and  produces  moderate  lengthening.  Care- 
ful measurements  of  the  position  of  the  trochanter  will  prove  its  position 
to  be  unchanged  in  most  cases.  Apparent  changes  in  the  length  of  the 
limb  are  simply  the  result  of  compensatory  postures,  which  permit  loco- 
motion without  motion  of  the  affected  joint. 

Deformity,  up  to  the  later  stages,  is  purely  muscular.  But  when  the 
capsular  and  other  ligaments  are  destroyed,  and  especially  when,  in  addi- 
tion, the  head  of  the  femur  has  been  shed  into  the  joint,  or  both  head, 
neck,  and  the  margins  of  the  cotyloid  cavity  have  been  eaten  away,  dis- 
location of  the  femur  upon  the  dorsum  ilii  is  very  apt  to  take  j^lace 
through  influence  of  continued  muscular  action.  Pain  then  ceases  and 
the  limb  becomes,  from  spasm  or  inflammation  of  the  adductor  muscles, 
adducted  and  inverted.  When  both  hip  joints  become  thus  dislocated 
the  legs  are  crossed  in  adduction,  and  produce  what  is  called  "  scissor  leg  " 
deformity.  Dislocation  is  determined  by  the  position  of  the  trochanter, 
characteristic  deformity,  and  actual  shortening.  Accidental  force  applied 
in  the  length  of  the  limb  may  drive  the  femoral  head  or  neck  through 
the  floor  of  the  acetabulum  if  the  latter  is  much  diseased  and  eroded. 
Occasionally  it  becomes  entirely  destroyed,  and  the  femur  slips  into  the 
pelvic  cavity  without  aid  of  outside  force. 

Abscess  is  a  very  frequent,  generally  inevitable,  symptom  and  compli- 
cation. Neglected  cases  almost  invariably  suppurate.  It  may,  or  may 
not,  produce  constitutional  disturbance  unless  septic  infection  take  place, 
when  hectic  and  some  degree  of  exhaustion  are  certain  to  follow.  Ab- 
scesses may  slowly  develop  and  be  circumscribed  by  the  capsule.  Or  it 
may  supervene  with  rapidity  and  give  rise  to  great  suffering  until  the 
capsule  ulcerates  or  ruptures.     Then  the  abscess  contents  escape  into  sur- 


464    DISEASES    OF    JOINTS,    CARTILAGES    AND    LIGAMENTS. 

rounding  structures  and,  perhaps,  give  rise  to  multiple  foci  of  suppura- 
tion or  a  dift'used  abscess.  In  either  case  the  pus,  earlier  or  later,  finds 
its  way  to  the  surface.  It  is  supposed  that  certain  abscesses  may  form  in 
the  inflamed  joint  surroundings  without  rupture  of  the  capsule.  Abscesses 
which  point  below  Pou part's  ligament  are  most  common  and  come  directly 
from  the  joint.  Those  which  appear  above  that  ligament  find  their  way 
through  the  acetabular  floor  into  the  pelvis,  and  thence  to  the  surface,  or 
into  the  rectum,  bladder,  or  intestines.  Either  variety,  however,  may 
point  in  the  gluteal  or  ischio-rectal  regions.  The  latter  must  not  be  mis- 
taken for  simple  ischio-rectal  abscess  or  fistula. 

Dl\gnosis. — By  ai)plication  of  the  above  given  diagnostic  signs  of  hip 
tuberculosis,  and  of  those  of  the  respective  diseases  which  follow,  it  may 
be  distinguished  from  rheumatism,  spinal  or  sacro-iliac  disease,  psoas  or 
iliac  abscess,  periostitis  of  the  upper  femur,  simple  extra-articular  abscess, 
spastic  paralysis,  and  injuries  or  displacements  of  the  femur. 

Treatment  should  be  begun  when  disease  is  but  suspected,  and  before 
unequivocal  signs  are  present.  The  fundamental  principles  of  treatment 
are:  to  build  up  the  general  health  by  such  measures  as  have  elsewhere 
been  indicated,  and  to  secure  absolute  rest  for  the  joint  until  all  acute 
symptoms  have  vanished.  Great  deformity  and  suppuration  will  occur 
unless  treatment  is  thorough  and  early. 

To  secure  the  necessary  repose,  the  patient  must  be  kept  strictly  upon 
his  back  in  bed,  with  pulley  extension  and  lateral  sand-bags.  He  must 
not  be  allowed  to  sit  up  in  bed.     If  necessary,  a  sheet  across  the  chest  or 

Fig.  274. 


Extension  of  the  limb  in  a  flexe'l  and  adducted  position.     (Marsh.) 


under  the  arm-pits,  and  tied  to  the  sides  or  head  of  the  bed,  must  be  era- 
ployed.  If  extension  with  the  limb  flat  upon  the  bed  produces  pain  or 
spine-aching,  then  the  direction  must  be  in  the  line  of  the  flexion  over  a 
wedge  shaped  pillow.  Extension  in  the  usual  manner,  in  these  latter 
cases,  produces  great  intra-articular  pressure  by  dragging  upon  the  psoas 
and  iliacus  muscles,  which  act  as  the  fulcrum  of  a  lever. 

After  this  extension  at  the  angle  of  deformity  has  been  kept  up  some 
time  the  limb  can,  from  day  to  day,  without  pain  or  resistance,  be 
brought  to  better  position  and,  finally,  into  the  axis  of  the  body.  During 
extension  the  foot  must  be  supported  laterally  and  vertically  to  prevent 


TUBERCULOSIS    OF    HIP-JOINT. 


465 


consecutive  deformity ;  to  the  same  end  and  to  prevent  atrophy,  massage 

of  the  limb,  without' motion  of  the  joint,  should  be  employed.     A  cradle 

to  hold  the  bedclothes  from  the  limlD  is  also 

desirable.    Counter-irritation  about  the  hip  Fig.  275. 

by  blisters  is  of  value  in  acute  stages,  and 

will  often  relieve  pain.  Excessive  pain  from 

joint  distention  can  be  at  once  stopped  by 

aspirating  the  joint.      The  needle   should 

be  introduced  through  the  gluteal,  not  the 

inguinal    region,   becaue   of  proximity  of 

vessels  in  the  latter  locality.    Pain  can  often 

be  moderated  by  simple  change  of  position, 

or  of  the  direction  of  extension. 

Extension,  as  above  described,  must  be 
kept  up,  perhaps  for  many  months,  until 
all  acute  symptoms  have  vanished  and  the 
thigh  is  in  the  body  axis.  Then  the  patient 
may  gradually  be  allowed  to  _get  up,  but 
must  constantly  wear  a  Thomas's,  or  other 
immobilizing  apparatus,  and  still  sleep  with 
the  extension  apparatus  applied. 

The  removable  extension  apparatus  of 
Morton  (Fig.  276)  is  the  most  convenient  for 
the  latter  purpose.  When  the  disease  has  still 
further  progressed  toward  cure,  night  exten- 
sion may  be  omitted  ;  and  when  motion  has 
become  normal,  or  when  consolidation  of 
the  hip  is  complete,  the  splint  can  be  ten- 
tatively left  off.  Six  to  ten  weeks  w^ill  be 
consumed  in  the  cure  of  even  the  most 
favorable  cases.  Non-use  of  the  joint,  alone, 
will  never  produce  stiffening  which  cannot 
afterward  be  readily  overcome. 

Late  stages,  of  the  disease  may  also  de- 
mand extension  or  splints  to  prevent  or 
reduce  the  shortening,  dislocation,  or  other 
deformity.  Forcible  reduction  of  deformity 
is  not  justifiable  at  any  stage,  nor  should  Thomas'  hip  splint. 

tendons  or  muscles   be   divided  except   in 

old  cases  where  they  impede  function  or  have  become  hopelessly  con- 
tracted. 

Abscesses  need  not  be  interfered  with  unless  they  produce  pain  or  con- 
stitutional disturbance,  or  show  tendency  to  open  spontaneously.  Then 
they  should  be  freely  incised,  curetted,  irrigated,  drained,  sutured,  and 
protected  from  septic  infection  by  proper  dressings.  Abscesses  which  open 
themselves,  or  are  surgically  infected,  at  once  set  up  hectic,  and  are  very 
apt  to  lead  to  such  changes  in  or  about  the  joint  as  to  necessitate  sub- 
sequent excision  or  amputation.  Abscesses  which  open  above  Poupart's 
ligament,  or  into  the  pelvic  contents,  are  almost  hopeless  affairs,  as  they 
indicate  pelvic  bone  involvement,  w^hich  is  practically  unamenable  to 
known  treatment. 

Exhaustion  from  continued  suppuration  may  demand  excision  of  the 
head  of  the  femur  and  extirpation  of  the  joint  and  infected  surroundings. 
This  may  effect  cure  if  all,  or  almost  all,  disease  can  be  eradicated. 

30 


466     DISEASES    OF    JOINTS,    CARTILAGES    AND    LIGAMENTS. 

Otlierwise,  the  patient  will  probably  succumb  to  the  effects  of  proloiifijed 
suppuration,  or  die  of  systemic  tubercular  complications.  In  suppurating 
cases,  consolidation  (usually  inseparable  from  great  deformity)  is  all  that 
we  can  hope  for;  under  the  circumstances  even  that  result  must  be  con- 
sidered good,  though  years  may  be  consumed  in  its  attainment.  If  the 
disease  has  travelled  along  the  shaft  of  the  femur,  or  osteomyelitis  has 
developed,  amputation  will  be  the  patient's  only  chance  for  life.  If  the 
ioint  has  become  ankylosed  in  an  awkward  po.sition,  no  treatment  for  its 
correction  should  be  undertaken  until  the  last  traces  of  disease  have  long 
since  disappeared.     Then  one  of  several  operations  may  be  employed : 

Fig.  276. 


Morton's  extension  apparatus. 

The  neck  of  the  femur  may  be  divided  by  introducing  an  Adams  saw 
through  a  small  incision  immediately  above  the  great  trochanter  and 
carried  down  until  the  neck  is  touched.  After  division  of  the  bone  and 
any  resisting  mu.scles  or  fa.scia,  the  extremity  is  brought  into  the  axis  of 
the  body,  and  either  in  that  position  treated  as  a  fracture  of  the  same 
region,  or,  as  soon  as  the  wound  has  firmly  healed,  at  once  starting  active 
and  passive  movements  that  a  false  joint  may  be  established.  Very  fair 
position  and  function  result  from  the  latter  procedure,  or,  if  dislocation 
does  not  exist,  the  osseous  material  interposed  between  the  acetabulum  and 
femur  may  be  divided  similarly.  A  chisel  should  never  be  used  for  these 
purposes  on  account  of  the  inevitable  traumatism  and  splintering  which 
are  thereby  produced.  Excision  of  the  head  of  the  femur  and  division  of 
resisting  structures  will  also  give  equally  good  position,  but  with  greater 
shortening  and  more  uncertain  function. 

Dislocations  resulting  from  hip  disease  can  never  be  permanently  re- 
duced.   Attempts  thereat  are  very  dangerous,  and  should  not  be  considered. 

When  a  patient  does  not  rally  under  treatment,  but  continues  to  lose 
ground,  and  especially  when  from  continued  suppuration,  excision  of  the 
joint  is  clearly  indicated  ;  but,  as  operation  in  these  stages  is  excessively 
dangerous,  the  chances  of  life  with  or  without  surgical  interference  must 
be  most  carefully  balanced.  Whenever  large  sequestrte  or  the  separated 
femoral  head  can,  by  probe  or  finger,  be  felt,  they  should  be  removed  by 
incision  and  the  surroundings  within  reach  curetted  and  washed  out  as 
thoroughly  as  possible. 


SYPHILITIC    ARTHRITIS.  467 

Prognosis. — Even  in  cases  cured  with  good  function  some  atrophy  and 
consequent  shortening  will  remain  and  the  limb  will  never  quite  catch  up 
to  the  other.  Interference  with  the  upper  epiphysis  makes  this  more 
marked.  Cure  with  stiffening  and  deformity  should  be  considered  a  good 
result  in  more  advanced  cases.  The  joint  may  suppurate,  apparently 
hopelessly,  for  even  years  and  then  consolidate.  It  is  never  safe  to  say  that 
any  case  cannot  recover  without  operation.  Amputation  can  sometimes 
be  done  with  comparative  safety  when  the  risks  of  excision  would  be  too 
great.  Excision  is  often  necessary'in  advanced  stages.  Months  and  years 
are  often  necessary  to  cure  completely  a  well-marked  case ;  eighteen 
months  may  be  called  the  average  duration  of  disease.  Relapses  are 
frequent,  particularly  should  the  patient  be  subjected  to  exhaustive  con- 
ditions, or  bad  diet  or  hygiene.  Other  joints  may  become  involved. 
Many  cases  succumb  to  intercurrent  tuberculosis  or  other  complications. 
Prognosis  should  always  be  most  guarded. 

Syphilitic  Arthritis. 

Syphilitic  arthritis  is  a  frequently  overlooked  disease,  which  is  almost 
limited  to  adults  suffering  from  tertiary  syphilis,  but  may  be  develoj^ed  in 
congenitally  syphilitic  children. 

During  the  later  manifestations  of  syphilis  the  deep  layers  of  the 
synovial  membrane  of  one  or  more  joints  becomes  infiltrated  and  swollen. 
This  thickening  extends  to  the  sub- and  superjacent  structures,  usually 
taking  the  form  of  innumerable  vari-sized  gummata.  The  endothelial 
layers  of  the  synovial  membrane  are  never  primarily  involved,  but  are 

Fig.  277. 


Syphilitic  arthritis  of  the  knee-joint,  showing  thickened  sub-synovial  tissue  and 
inflamed  bone.     (Marsh.) 

bulged  into  the  joint  cavity  by  the  new  growths  pressing  from  beneath. 
Effusion,  if  present,  is  always  slight.  The  disease  in  its  earlier  stages  much 
resembles  other  subacute  affections  of  like  situations.  When  gummata 
have  developed,  however,  the  diagnosis  is  evident,  for  they  can  often  be 
felt,  which,  with  the  general  spongy  feeling  of  the  joint,  symmetry  of  the 


468    DISEASES    OF    JOINTS,    CARTILAGES    AND    LIGAMENTS. 

joint  involvement,  perhaps  slight  pain,  creaking,  and  effusion,  makes  the 
real  nature  of  the  case  plain.  Extensicm,  rest,  counter-irritants,  and  anti- 
svphilitic  remedies  embrace  the  necessary  treatment,  to  all  of  which,  liow- 
ever,  the  disease  will  often  prove  most  obdurate.  Firm,  fibrous  adhesions 
may  remain  after  absorption  of  the  gummata  and  more  or  less  cripple 
the  articulation,  or,  more  rarely,  the  nodules  may  soften,  suppurate,  and 
discharge  into  the  joint  cavity,  giving  rise  to  purulent  arthritis. 

Syphilitic  arthritis  also  as  frequently  invades  a  joint  from  the  bone 
ends.  Specific  arthritis  enlarges  the  bone  extremities,  giving  rise  to  all 
the  symptoms  of  syphilitic  ostitis  elsewhere,  and  the  joint  is  speedily  in- 
volved in  suppurative  destruction,  which  proves  rebellious  to  all  save 
heroic  surgical  measures  such  as  excision,  or  even  amputation. 


Osteo-arthritis  (Arthritis  Deformans). 

Osteo-arthritis  is  a  form  of  chronic  arthritis  which  is  almost  limited  to 
later  life,  being  disposed  to  by  constitutional  depravity  and  excited  by 
diseased  conditions  of  the  proximal  bone-ends  or  synovial  membranes,  and 
traumata. 


Fir. 


Changes  in  hip-joint  dependent  upon  osteo-arthritis.     (Marsh.) 

The  disease  commences  in  the  articular  cartilages,  which  rapidly  lose 
their  smoothness  and  pearly  color,  become  of  a  yellowish  tint,  and 
wear  away  at  the  points  of  pi-essure  contact,  even  into  the  cancellated 
structure  of  the  subjacent  bones,  whilst  at  places,  such  as  ligament  and 
muscle  attachments,  where  no  pressure  is  brought  to  bear,  cartilage  hy- 
pertrophy and  thickening  occur  and  give  to  the  joint  a  characteristic 
deformed  appearance.  One  or  more  of  these  nodules  may  subsequently 
become  isolated  and  become  "  loose  bodies  "  in  the  joint.  Later  the 
synovial  membrane  becomes  thickened  and  exceedingly  vascular.  At 
this  stage  effusion  may  appear,  but  is  not  inevitable :  marked  distention 
is  always  transitory;  occasionally  slight  effusion  may  last  throughout,  but 
as  often  it  will  entirely  disappear.     Now  the  cartilaginous  outgrowths 


ATROPHIC    ARTHRITIS.  469 

begin  to  ossify,  and  from  the  wearing  down  of  the  bone  the  joint  surface 
becomes  broad  and  at  the  same  time  extremely  mobile  by  the  consequent 
relaxation  of  the  surroundiug  ligaments  and  other  tissues,  which  them- 
selves at  this  stage  have  become  softened,  atrophied,  or  even  destroyed. 
Displacements  of  the  bones  composing  the  joint  usually,  at  this  stage, 
takes  place,  and  great  deformity  results.  Such  displacements  constitute  a 
variety  of  so-called  "  pathological  dislocations,"  and  are  due  to  the  con- 
tinual activity  or  spastic  contraction  of  the  neighboring  muscles  after  the 
joint  structures  have  been  so  weakened  as  not  to  be  able  to  resist  their 
displacing  action.  Ankylosis  in  any  position  may  finally  end  the  altera- 
tive process. 

The  first  symptoms  of  osteo-arthritis  are  dull,  aching  pains  in  the  joints 
shortly  followed  by  pain  and  creaking  upon  motion.  Subsequent  symp- 
toms depend  greatly  upon  the  rapidity  with  which  the  particular  case 
may  progress.  The  disease  may  run  its  full  course  in  a  few  months  or 
continue  indefinitely.  Frequently  it  has  had  origin  in  some  form  of  in- 
jury, and  without  the  exercise  of  great  care  in  diagnosis  deformities  pro- 
duced by  the  arthritis  may  readily  be  mistaken  for  neglected  fracture, 
dislocations,  or  other  injuries.  Treatment  of  this  form  of  arthritis,  un- 
fortunately, will  almost  always  prove  unavailing.  Those  measures  which 
are  best  calculated  to  improve  the  general  physical  condition  are  always 
to  be  applied,  together  with  massage,  hot  and  cold  douches,  and  perhaps 
counter-irritation  locally.  Excessive  deformity  can  usually  be  prevented 
by  splints,  extension,  plaster  bandages,  and  division  of  tendons. 

Atrophic  Arthritis  (^Charcot's  Disease). 

Atrophic  arthritis  is  a  retrograde  arthropathy  which  may  develop  in 
the  later  stages  of  locomotor  ataxia.  Etiologically,  it  is  directly  de- 
pendent upon  those  changes  in  the  central  nervous  system  which  are 
present  in  ataxia,  and  most  likely  due  to  interference  with  trophic 
nerves.  In  its  early  manifestations  the  disease  much  resembles  osteo- 
arthritis, but  later  runs  a  very  distinctive  course.  The  presence  of  a  group 
of  ataxic  symptoms  would  always  settle  the  diagnosis  in  favor  of  atrophic 
arthritis. 

Beginning  in  any  joint  or  number  of  joints,  but  usually  in  the  knee, 
the  synovial  membrane  is  thickened,  and  some  effusion  is  poured  out; 
grating  with  some  pain  and  disability  supervene  and  ostitic  thickenings 
begin  to  form.  Later,  pain  almost  disappears,  great  absorption  of  contact 
points  of  the  bones  takes  place,  and  wide  separation  of  articulating 
surfaces  with  great  resultant  deformity  occurs.  The  ligaments  have  by 
this  time  become  greatly  stretched  and  disintegrated ;  but  a  most  sur- 
prising and  diagnostic  symptom  is  the  preservation  of  more  or  less  loco- 
motive function  of  the  joint  until  a  very  late  stage  of  the  disease.  Ostitic 
formations  are  much  less  marked  in  atrophic  arthritis  than  in  osteo-arthri- 
tis, but  erosion  of  the  bones  is  markedly  greater  in  the  former. 

Months  and  years  are  usually  required  for  the  joint  symptoms  of  ataxia 
to  run  their  course,  but  occasionally  instances  are  met  with  where  but  a 
few  months  are  necessary  to. carry  the  process  to  its  utmost  limit.  No  spe- 
cial local  treatment  can  be  recommended ;  our  efforts  should  be  toward 
removal  of  the  cause. 


470   diseases  of  joints,  cartilages  and  ligaments. 

Hysterical  and  Neuralgic  Joint  Affections. 

These  may  be  classed  together,  as  both  are  purely  subjective  disorders. 
Though  not  identical  they  are  frequently  exceeding  difficult  to  differenti- 
ate. Females  more  often  than  males  are  affected.  In  the  hysteroid  affec- 
tion pain  may  be  complained  of  out  of  all  proporti(ni  to  other  symptoms, 
perhaps  combined  with  voluntary  or  involuntary  fixation.  Slight  swell- 
ing of  the  joint  may  supervene,  owing  to  increased  vascular  tension  there- 
about, but  more  often  the  peculiar  avascular  condition  of  hysteria  will 
render  the  joint  pale  and  bloodless. 

Hvpertesthesia,  either  local  or  general,  will  be  present ;  pain  may  be 
definitely  located  or  shift  its  position. 

The  joint  can  always  be  freely  moved  under  ether,  often  also  when  the 
patient's  attention  is  diverted  or  under  application  of  extension  when 
long  continued  ;  false  ankylosis  and  muscular  wasting  may  take  place. 
Symptoms  are  mostly  anomalous,  varying,  and  inconsistent,  and  apt  to  be 
but  a  single  group  in  an  hysterical  aggregate. 

Great  caution  must  be  observed,  and  close  watching  and  repeated  ex- 
aminations resorted  to  before  positive  opinion  of  these  cases  is  expressed. 

Treatment  of  these  neurotic  joint  affections  should  include  special 
attention  to  the  general  health  as  well  as  the  judicious  use  of  massage, 
electricity,  anti-neuralgics,  and  anti-periodics ;  possibly  counter-irritation, 
prolonged  extension,  and  occasional  movements  under  ansesthesia. 

Ankylosis. 

By  ankylosis  is  meant  that  condition  of  a  joint  free  from  active  disease 
in  which  motion  has  become  restricted  or  abolished. 

When  all  motion  is  impossible  ankylosis  is  complete;  when  partial  mo- 
tion remains  or  can  be  developed,  incomplete. 

Ankylosis  may  be  true  or  false ;  true  when  the  bones  of  the  articulation 
have  grown  together  by  cancellated  bone  structure  ;  and  false  when  the  joint 
is  impeded  by  fibrous  adhesions,  situated  within  or  surrounding  its  capsule. 
True  ankylosis  or  osseous  consolidation  is  also  called  synostosis.  The  con- 
dition is  not  in  itself  a  disease,  but  is  the  result  of  preexistent  disease,  and 
the  term  ankylosis  should  not  be  applied  to  the  usual  coincident  stiffness 
of  inflammation. 

In  true  ankylosis  the  joint  as  a  joint  is  destroyed,  the  cartilages  have 
disappeared  over  more  or  less  of  its  area  and  the  cancellated  tissue  of  bone 
ends  has  grown  together.  True  ankylosis,  therefore,  cannot  take  place 
until  cartilage  and  its  subjacent  bone  layer  have  been  destroyed  upon  the 
surface  of  the  joint.  This  may  be  accomplished  by  disease  or  by  the  sur- 
geon, as  in  the  complete  bony  ankylosis  which  follows  a  successful  excision 
of  the  knee. 

The  uniting  bony  substance  may  be  extra-  as  well  as  intra-capsular,  but 
the  extra-capsular  portion  is  usually  nothing  more  than  a  calcification  of 
ligaments  or  other  surroundings,  which  is  common  to  either  variety.  The 
joint  cavity  is  generally  totally  obliterated  before  any  bony  union  takes 
place.  The  true  variety  of  stiffening  always  is  caused  by  either  fractures 
or  long-continued  destructive  inflammatory  disorder. 

False  or  fibrous  complete  ankylosis  may  be  due  to  either  of  the  above 
causes,  to  trophic  changes,  to  organization  of  tuberculous  or  other  dis- 
ease products,  or  to  non-use  of  the  articulation  for  a  long  period  of  time 


ANKYLOSIS. 


471 


after  injury  or  disease.  The  greater  proportion  of  all  joint  restriction 
results  from  injury,  when  insertions  of  tendons  are  stretched  or  torn,  the 
capsule  lacerated,  and  blood  or  lymph  effused.  These  products  subse- 
quently organize  and  bind  folds  of  the  capsule  as  well  as  surrounding 
parts  together  and  motion  becomes  impeded  and  painful  or  impossible. 
Fibrous  bands  may  also  form  connecting  the-  joint  surfaces.  If  these 
adhesions  are  not  early  interfered  with  they  will  firmly  organize  and 
contract  or  may  even  become  calcareous.  But  again  ankylosis  of  the 
false  varietv  may  be  complete  and  yet  every  structure  of  the  joint  remain 
almost  unchanged,  all  adhesions  being  extra-articular. 

Impeded  joint-motion  from  outside  cause,  such  as  muscular  spasm, 
hysteria,  burns,  cicatrices,  etc.,  is  termed  "spurious  ankylosis,"  but  may 
result  in  false  ankylosis  through  contraction  of  and  Avasting  of  the  joint- 
structures  from  long-continued  inactivity.  Nerve  injury  also  may  thus 
give  rise  to  spurious  ankylosis,  especially  when  small  joints  are  concerned. 
Diagnosis  of  the  variety  of  ankylosis  can  usually  be  made  from  the 
history  of  the  case,  but  sometimes  differentiation  will  be  found  impossible. 
Except  in  trivial  cases,  all  manipulations  should  be  made  with  anaesthesia. 
If  the  slightest  motion  remains  the  case  is  not  one  of  bony  consolidation. 
If  judicious  force  under  ether  fails  to  produce  movement,  the  case  had 
better  be  considered  one  of  bone  variety  rather  than  subject  the  part  to 
dangerous  manipulation,  for  with  such  firm  adhesion  the  exact  diagnosis 
would  be  of  little  aid  in  treatment. 

Treatment  of  ankylosis  is  extremely  important  and  successful  if 
properly  apprehended  and  applied.  It  should  always  be  instituted  as 
early  as  possible,  but  never  while  the  slightest  heat  or  redness  of  the  part 
persists,  but  a  moderate  degree  of  swelling  may  be  ignored.  Manipulation 
is  of  what  treatment  mainly  consists.  If  this  is  productive  of  pain  (and  it 
practically  always  is)  nitrous  oxide  or  ether  anaesthesia  should  first  be  in- 
duced. No  great  force  is  ever  justifiable. 
Fig.  279.  nor  should  a  known  case  of  true  ankylosis 

ever  be  subjected  to  manipulation.  If,  with 
moderate  force,  adhesions  are  felt  to  break, 
the  joint  should  gradually  and  gently  be  put 
through  its  range  of  motions,  but  manipula- 


Modified    Stromeyer    splint    for        Modified  Stromeyer  splint  for  ankylosis  of   elbow, 
ankylosis  of  knee. 

tion  should  never  be  kept  up  more  than  five  or  ten  minutes  at  one  sitting. 
If  it  requires  considerable  force  and  the  adhesions  seem  very  tough  and 


472     DISEASES    OF    JOINTS,    CARTILAGES    AND    LIGAMENTS. 

strong,  the  outlook  is  not  favorable,  and  after  a  few  unsuccessful  sewiees 
this  form  of  treatment  should  be  abandoned,  as  also  should  it  be  given 
up  if  after  each  manipulation  there  is  a  return  of  inHammation.  This 
latter  complication,  however,  is  liable  to  follow  once  or  twice  in  any 
case  and  should  be  prohibitory  only  when  frequently  repeated  or  sevej-e. 
When  it  does  occur,  no  further  manipulation  should  be  attempted  until 
the  parts  are  again  free  from  abnormal  heat. 

Certain  varieties  of  stitiness  can  be  manipulated  every  day  or  two, 
others  may  require  a  longer  interval,  lietween  times  motion  may  be  pre- 
served by  means  of  extension,  splints,  or  the  Stromeyer  screw.  (Figs.  279, 
280.)  Movements  should  be  kept  up  until  the  joint  regains  its  former 
motions,  or  until  no  further  improvement  can,  by  this  means,  be  obtained. 
AVithout  securing  motion,  a  fibrous  ankylosis  at  an  inconvenient  angle 
may,  by  manipulation,  be  changed  to  one  of  more  c(mifort  or  utility. 
Where  tendons  have  contracted,  or  are  in  unrelieved  spasm,  they  should 
be  divided  as  a  preliminary  to  passive  motion ;  their  division  alone  will 
accomplish  little  or  nothing. 

AVhen  a  joint  has  been  extensively  diseased,  as  in  tuberculosis,  manipu- 
lation is  useless  and  dangerous,  but  where  adhesions  are  recent  it  is  most 
successful,  and  especially  so  when  the  trouble  is  mainly  resident  in  the 
peri-articular  structures. 

Where  fibrous  ankylosis  has  become  very  resistant  and  firm,  nothing 
except  the  knife  or  chisel  should  be  used  to  separate  the  adhesions. 

Bony  ankylosis,  if  it  is  thought  expedient  or  necessary,  may  like- 
wise be  treated  by  driving  a  chisel  or  saw  through  the  line  of  union  if 
the  connecting  and  surrounding  tissues  are  healthy  ;  otherwise,  or  when 
there  is  great  displacement  or  deformity,  excision  of  the  joint  or  osteotomy  of 
one  or  the  other,  or  both  of  the  proximate  bone  shafts  would  be  preferable; 
more  especially  at  the  elbow,  knee,  and  hip. 

Recurring  ankylosis,  if  troublesome,  may  demand  either  division  of 
tendons  or  excision  of  the  joint.  Many  cases  will  require  a  brace  for 
some  time  after  practical  recovery,  plus,  perhaps,  extension  at  night. 
(See  Osteotomy  ;  Excision  of  Joints.) 

Loose  Bodies  ix  Joints. 

These  are  not  of  uncommon  occurrence,  and  consist  of  entirely  loose  or 
pediculated  masses  of  varying  size,  which  only  demand  attention  when 

they  impede  function  or  cause  pain. 
They  arise  from  :  1,  condensed  fibrous 
exudate ;  2,  organized  blood-clot ;  3, 
broken  osteophytes,  as  in  osteo-arthri- 
tis  ;  4,  actual  foreign  bodies,  as  bullets 
or  needles,  either  encrusted  or  not ; 
5,  pieces  of  articular  cartilages,  with, 
perhaps,  sub-adjacent  bone,  broken  off 
or  exfoliated  into  the  joint  cavity ;  6, 
hypertrophied  and  hardened  portions 
of  the  synovial  membrane  ;  7,  irritative 
development  of  cartilaginous  cells  em- 
bedded in  the  deep  layers  of  synovial 

Trochlea  of  humerus,  showing  for       memoraue. 

mation  and  connection  of  loose  bodies  The  first  four  classes  are  never  pedi- 
dereloping  from  synovial  membrane,  culated  ;  the  last  three  frequently  are  ; 
(Miller.;  the  seventh  is  always  SO  at  first.     In  the 


INJUEIES    OF    .JOINTS.  473 

latter  class,  owing  to  severe  irritation,  one  or  more  of  the  depots  of  in- 
active cartilage  cells,  which  are  to  be  found  studding  the  deep  layers  of 
articular  cartilages,  take  on  active  growth,  press  forward  the  layers  of 
membrane  between  them  and  the  joint  cavity,  and  become  prominent  as 
minute  nodules.  Combined  growth  and  the  movements  of  the  joint  soon 
stretch  their  attachments  and  they  become  jDediculated,  which  connec- 
tion is  apt  to  be  snapped  during  some  motion  of  the  joint,  and  the  now 
unattached  bodies  float  free. 

Loose  bodies  almost  never  are  found  in  other  than  hinge  joints,  and 
nearly  always  in  the  knee.  They  may  be  single  or  in  great  numbers, 
according  to  their  mode  of  origin. 

Sympto:\is  arise  when  the  bodies  get  caught  between  articulating  sur- 
faces. Commonly  they  become  so  caught  for  a  second,  and  at  once  slip 
out  again.  In  either  case  the  symptoms  only  vary  in  degree  and  duration. 
When  the  accident  takes  place  the  joint  surfaces  are  forced  apart  and 
bruised  or  scratched,  and  the  ligaments  are  put  upon  a  severe  stretch,  the 
joint  locks,  and  if  it  be  the  knee,  the  person  is  thrown  to  the  ground  in 
great  agony,  sick  and  faint.  If  the  body  slips  out  again,  pain  and  other 
symptoms  instantly  cease,  until  the  accident  again  takes  place.  Other- 
wise symptoms  persist  until  relieved  by  the  surgeon.  Very  rarely,  a  joint 
becomes  locked  in  this  way  without  pain.  Any  variety  may  be  followed 
by  synovitis,  but  this  is  not  common  or  serious  except  in  joints  already 
diseased  or  predisposed  thereto.  Frequently  recurring  entanglement  is 
apt,  in  time,  to  originate  chronic  synovitis  with  persistent  effusion. 

Bodies  can  usually  be  felt  beneath  the  joint  covering,  more  or  less  defi- 
nitely fixed  in  position ;  but  sometimes  cannot  be  felt,  or  disappear  from 
touch  for  a  time,  or  uj^on  motion  of  the  joint,  and  reappear  either  errati- 
cally or  upon  certain  motion  or  manipulation — as  a  rule,  best  understood 
by  the  patient  himself,  as,  indeed,  is  often  the  best  method  of  unlocking 
the  joint. 

Contrary  to  the  case  where  dislocation  of  joint  cartilages,  such  as  the 
semi-lunar,  has  taken  place,  loose  bodies  usually  lock  the  articulation  in 
anomalous  positions.  The  history,  method  of  occurrence,  and,  perhaps, 
palpable  presence  of  the  loose  body,  will  furnish  enough  evidence  for 
differential  diagnosis. 

Such  manipulation  as  each  individual  case,  or  the  patient  himself,  may 
suggest,  will  unlock  most  joints.  If  this  fail,  nothing  short  of  exploring 
the  joint  and  removing  the  oflending  body  will  avail.  Often  wearing  a 
.brace  or  pad  will  prevent  frequent  joint-locking  by  securing  the  body  in 
one  position,  or  by  restricting  certain  movements  of  the  joint  which  invite 
the  body  between  articulating  surfaces. 

If  the  distress  therefrom  becomes  great,  the  bodies  should  be  removed 
by  incision.  To  do  this  it  should  be  firmly  secured  before  anaesthesia  by 
pressure  of  a  finger  or  strap,  or  better,  by  transfixion  with  an  aseptic  pin 
or  needle.  If  this  jDrecaution  is  not  taken,  the  body  will  often  have  dis- 
appeared beyond  reach  into  the  joint  when  the  incision  is  made  over  its 
former  site.  If  the  bodies  are  numerous,  or  cannot  be  brought  near  the 
surface,  nothing  short  of  exploratiou  of  the  joint  and  the  removal  of  all 
present  in  or  around  it  will  avail. 

IxjuRiEs  OF  Joints. 

Contusions  of  joints  call  for  no  other  treatment  than  rest  and  evaporat- 
ing lotions.  Succeeding  complications,  such  as  inflammation  or  abscess, 
are  to  be  treated  as  elsewhere  described. 


474     DISEASES    OF    JOINTS,   CARTILAGES    AND    LIGAMENTS. 

Spidiiis — Contusiug  injuries  usually  accompany  or  complicate  sprains, 
which  may  be  defined  as  a  condition  of  more  or  less  stretching,  bruising, 
or  laceration  of  the  contents  or  immediate  surroundings  of  a  joint,  and  are 
always  the  result  of  forcible  motion  of  an  articulation  beyond  its  range  of 
function,  or  in  a  direction  contrary  thereto;  in  fact,  sprains  are  mild 
varieties  of  dislocations.  The  causative  force  may  act  directly  or  indirectly. 
The  hinge-joints  are  those  usually  affected.  In  the  milder  forms  the  sur- 
rounding ligaments  or  tendon  insertions  may  be  simply  stretched,  and  a 
few  vessels  of,  or  the  synovial  membrane  itself,  be  lacerated.  This  is  fol- 
lowed by  an  intense  hyperemia  of  the  entire  joint  and  surroundings, 
especially  of  the  subserous  vessels  of  the  synovial  membrane,  which  often 
leads  on  to  synovitis;  rarely  to  the  suppurative  form  and  to  arthritis, 
unless  the  subject  is  tuberculous.  Swelling  and  (edema  quickly  set  in 
and  effusion  rapidly  distends  the  joint  cavity.  This  e.xudate  may  become 
plastic  and  even  involve  surrounding  ligaments  and  tendon  sheaths. 
Hemorrhage  into  the  joint  may  take  place. 

Symptoms. — The  injury  is  accompanied  with  intense  sickening  pain, 
perhaps  vomiting  and  shock,  and  more  or  less  disability,  according  to 
the  extent  of  injury.  The  joint  almost  immediately  sw'ells  and  becomes 
hot,  and  soon  begins  to  throb  with  dull  pain.  The  limb  will  be  found 
in  that  position  which  permits  least  tension  in  the  joint.  Motion  is 
exceedingly  painful,  and  if  ligaments  are  extensively  torn,  is  anomalous. 
If  diagnosis  cannot  be  readily  made  without  much  manipulation,  anes- 
thesia should  be  induced.  Differential  diagnosis  from  fracture,  even 
under  ether,  is  often  difficult ;  sometimes,  as  at  the  wrist  and  ankle  joints, 
impossible.  AVherever  this  doubt  exists  the  case  should  be  treated  as  for 
fracture.  Strict  adhesion  to  this  rule  will  save  many  an  unfortunate 
result. 

Treat.ment. — The  case  seen  early — within  an  hour  or  two — and  diag- 
nosis established,  a  sprained  joint  should  be  plunged  into  either  very  cold 
or  very  hot  water,  and  there  allowed  to  remain  twenty  or  thirty  minutes, 
until  the  bloodvessels  about  it  have  thoroughly  contracted.  Swelling, 
effusion,  and  inflammation  are  thus  prevented.  It  is  then  elevated  and 
firmly  bandaged  from  below  upward.  The  extremity  is  to  be  kept  thus 
bandaged  and  elevated  for  twenty-four  hours,  when  a  phxster  or  other 
snug-fitting  dressing  should  be  applied,  and  he  may  then  be  allowed  to  sit 
up.  The  cast  is  to  be  renewed  as  swelling  goes  down,  and  left  on  from 
one  to  three  weeks,  according  to  the  extent  of  the  injury.  Passive  motion 
and  counter-irritation  by  liniments,  or  otherwise,  may  then  be  necessary, 
or  a  supporting  brace  may  become  advisable. 

If,  however,  the  sprain  does  not  come  to  hand  until  swelling,  effusion, 
or  inflammation  has  set  in,  success  with  the  bath  will  not  be  so  marked, 
and  hot,  cold,  or  evaporating  lotions,  the  ice-bag,  and  i)erhaps  poultices  and 
counter-irritation  will  take  the  place  of  tight  bandaging  until  swelling 
goes  down  sufficiently  to  justify  the  plaster  dressing. 


Wounds  of  Joints. 

Wounds  of  joints  are  of  two  classes ;  those  opening  the  joint  through 
the  integument,  including  such  accidental  wounds  as  lacerated,  incised, 
punctured  or  gunshot,  and  the  premeditated  ones  of  the  surgeon;  and 
those  attacking  the  articulation  from  beneath  the  integument,  such  as  frac- 


WOUNDS    OF    JOINTS.  475 

tures  and  dislocations.  The  latter  class  may  communicate  with  the  air  and 
likewise  become,  as  are  all  those  from  without,  open  (compound)  wounds. 
All  open  wounds  of  joints  may  be,  or  become,  septic  or  poisoned  from 
outside  influences ;  but  closed  joint  wounds  can  only  become  infected  or 
septic  from  the  blood,  by  sloughing  of  their  coverings,  lymphatic  conduc- 
tion, or  from  rupture  of  the  deep  glands  of  the  skin. 

Diagnosis. — Closed  wounds  of  joints  have  been  discussed  under  other 
headings,  and  need  not  further  concern  us  here.  Open  wounds  in  the 
neighborhood  of  joints  now  have  comparatively  few  points  of  diagnosis  or 
differential  diagnosis  capable  of  puzzling  the  surgeon,  because  the  very 
mode  of  treatment  establishes  the  exact  nature  of  the  wound.  That  is,  all 
wounds  must  be  thoroughly  cleansed.  Hence  wounds  near  joints  are  to 
be  opened  up  to  their  bottom,  if  at  all  deep,  and  incidentally  their  nature 
is  thus  established.  The  danger  of  mistaking  serious  for  trivial  injuries 
until  sepsis  sets  in  is  thus  avoided.  Joint  wounds  may  be  palpable  from 
their  extent,  display  of  cartilage,  flow  of  synovial  fluid,  or  be  made  so  by 
exploration. 

If  the  case  is  old,  a  wound  which  has  entered  a  bursa  and  set  up  sup- 
puration must  not  be  mistaken  for  articular  involvement.  To  avoid  such 
mistakes,  even  in  cases  where  there  seems  to  exist  no  doubt  that  the  joint 
is  involved,  it  should  not  be  laid  open  before  penetration  of  its  cavity  is 
proved. 

Early  reached  and  properly  treated,  uncomplicated  open  joint  wounds 
should  almost  always  progress  favorably  to  perfect  cure,  with  unimpaired 
utility.  But  if  infection  has  taken  place  and  suppuration  set  in,  the  case 
is  one  of  utmost  gravity.     (See  Acute  Purulent  Arthritis.) 

Treatment. — Any  wound  or  open  fracture  near  a  joint  should  be  re- 
garded with  extreme  care  and  suspicion.  The  surrounding  parts  should 
be  cleansed  and  the  wound  then  investigated.  If  the  wound  stop  before 
entering  the  joint  it  should  be  cleansed,  sutured,  and  the  limb  be  put  upon 
a  splint  until  fairly  healed.  But  if  a  probe  or  the  finger  carried  in  enters 
the  joint,  or,  this  failing,  the  wound  has  been  laid  open  and  proved  to 
penetrate,  the  opening  into  the  synovial  cavity  should  be  made  sufficiently 
large  to  wash  out  the  joint  thoroughly  with  1  :  1000  corrosive  sublimate 
solution. 

The  articulation  having  been  freed  from  foreign  matter  and  the  syno- 
vial membrane  and  integument  separately  sutured  with  chromic  catgut, 
a  dressing  and  splint  are  applied  and  left  for  three  weeks,  when 
passive  movements  are  to  be  commenced.  Subsequent  local  or  constitu- 
tional signs  of  inflammation  in  the  joint  will  indicate  immediate  re-open- 
ing, irrigation,  and  possibly  curetting  of  the  cavity,  and  the  introduction 
of  a  rubber  drain-tube  to  the  bottom  of  the  joint. 

Violent  septic  arthritis  must  be  met  with  free  incisions,  curetting,  wash- 
ing, and  gauze  packing  of  the  entire  joint.  Or,  if  these  measures  fail,  and 
without  resorting  to  them  in  aged  or  broken-down  individuals,  excision 
or  amputation  must  immediately  be  performed. 

Open  or  compound  dislocations  are  to  be  cleansed,  reduced,  the  joint 
irrigated,  usually  a  drain-tube  introduced,  the  synovial  membrane,  torn 
ligaments,  etc.,  sutured  as  far  as  possible  into  normal  position  and  the 
outer  wound  united. 

If  reduction  cannot  be  effected,  even  after  free  incisions  have  been 
made,  the  end  of  the  dislocated  bone  must  be  excised. 

Sometimes  a  splinter  of  an  open  fracture  will  wound  a  joint  situated  a 
long  distance  from  the  original  injury.     Especially  is  this  apt  to  occur  in 


476    DISEASES    OF    JOINTS,    CARTILAGES    AND    LIGAMENTS. 

longitudinal  fractures  of  the  upper  tibia.  Proper  treatment  of  the  open 
fracture  would,  however,  eliminate  danger  from  the  joint  opening,  but  a 
septic  condition  of  the  fracture  will  almost  invariably  be  followed  by  dire 
consequences  to  the  knee,  and  perhaps  kill  the  patient.  Open  and  com- 
muuicating  fractures  involving  a  joint  demand  prt)mpt  exjiloration  of  the 
same,  removal  of  fragments,  blood,  etc.,  or  excision,  or  amjjutation,  ac- 
cording to  circumstances.  Precisely  the  same  is  to  be  said  for  gunshot 
wounds  involving  joints  ;  if  the  joint  surfaces  are  only  grooved  or  cracked, 
however,  washing  out  and  drainage  will  alone  be  required. 

In  all  cases  of  joint  injury  rest  and  immobilization  for  weeks  must  be 
insisted  upon. 

If  eifusion,  swelling,  and  disability  persist  after  healing  of  a  joint 
wound,  active  counter-irritation,  a  rubber  l)andage,  massage,  or  some  form 
of  supporting  apparatus  must  be  employed. 

(See  Chronic  Arthritis,  Chronic  Synovitis,  Ankylosis.) 


Dislocations. 

Definition. — A  dislocation  or  luxation  is  a  violent  displacement  of 
a  bone  from  its  normal  relation  with  another  bone  at  the  place  of  mutual 
articulation.  The  term  dislocation  is  similarly  applied  to  an  intra-articular 
fibro-cartilage  when  it  has  been  displaced  from  its  normal  position.  It 
will  be  seen  that  I  limit  the  term  to  articular  displacements  due  to  trau- 
matic or  muscular  violence,  as  I  regard  the  so-called  pathological  or  spon- 
taneous dislocations  as  mere  symptoms  of  other  diseases,  generally  arthritis 
or  paralysis  of  muscles,  and  the  congenital  dislocations  instances  of  malfor- 
mation from  arrest  of  development  or  fa?tal  disease.  I  admit  the  possi- 
bility of  congenital  dislocations  being  sometimes  due  to  violence  received 
by  the  foetus  in  utero,  but  such  a  bare  supposition  does  not  warrant  the 
application  of  the  term  dislocation  to  conditions  which  resemble  other  con- 
genital arrests  of  development.  The  term  "  old  "  is  applied  to  dislocations 
which  have  not  been  reduced  for  some  time  after  their  occurrence.  The 
definition,  it  will  be  observed,  is  quite  arbitrary  and  ambiguous,  and  no 
rules  can  be  laid  down  to  demark  the  exact  time  when  an  acute  disloca- 
tion becomes  one  of  this  class.  Thus  a  dislocated  elbow  is  commonly  spoken 
of  as  "  old  "  when  it  has  remained  unreduced  for  three  weeks,  and  a  sim- 
ilar persisting  lesion  at  the  shoulder-joint  assumes  the  term  when  it  has 
existed  fi'om  four  to  seven  months. 

That  bone  which  is  more  remote  from  the  trunk  is  the  one  which  is  said 
to  be  dislocated.  Thus  dislocation  at  the  hip  is  called  a  dislocation  of  the 
femur,  not  of  the  innominate ;  dislocation  at  the  knee  is  termed  a  disloca- 
tion of  the  tibia,  not  of  the  femur ;  and  dislocation  of  the  ankle  is  de- 
nominated a  dislocation  of  the  tarsus.  The  displacement  of  the  bone 
maybe  in  various  directions;  thus,  backward,  forward,  upward,  down- 
ward, or  laterally.  Each  joint  is  liable  to  sustain  dislocation  in  certain 
directions  rather  than  in  others,  this  tendency  being  due  to  the  shape 
of  the  articulating  surfaces  and  the  manner  of  muscular  and  ligamentous 
attachments  about  the  joints. 

Dislocations  at  amphi-arthrodial  joints,  such  as  are  found  between  con- 
tiguous vertebral  bodies,  at  the  pubic  symphysis,  and  between  the  seg- 
ments of  the  sternum,  are  sometimes  called  diastases,  I  prefer  to  restrict 
the  term  diastases  to  epiphyseal  fractures,  and  to  apply  the  words  disloca- 
tion and  luxation  to  these  as  to  other  joints. 


DISLOCATIONS.  477 

A  dislocation  is  complete  when  no  portion  of  the  articular  surfaces 
remain  in  contact.  Complete  dislocations  are  rare  in  hinge-joints,  but 
common  in  ball-and-socket  articulations.  Incomplete  or  partial  disloca- 
tions, often  called  subluxations,  are  luxations  where  the  displacement  is 
not  sufficiently  great  to  cause  loss  of  mutual  contact  between  portions 
of  the  articular  surfaces.  As  in  fractures  so  in  dislocations,  the  lesion 
may  be  complicated.  Laceration  of  soft  parts,  rupture  of  large  vessels 
or  of  nerve-trunks,  fractures  involving  or  not  involving  the  joint-cavity, 
and  similar  accompaniments,  constitute  the  complications  that  make  the 
term  complicated  dislocation  applicable.  When  an  external  wound  leads 
to  the  seat  of  dislocation  the  injury  is  called  an  open  dislocation,  in  con- 
tradistinction to  one  not  so  exposed  to  the  entrance  of  air,  which  is  a 
closed  dislocation.  The  terms  "  compound  "  and  "  simple  "  are  as  unde- 
sirable here  as  in  connection  with  fractures,  and  I  have  accordingly 
employed  the  better  terms,  "  open  "  and  "  closed." 

When  a  dislocated  bone  has  its  primary  jDosition  altered  by  efforts  at 
reduction,  involuntary  muscular  action,  or  other  cause,  a  consecutive  or 
secondary  dislocation  is  said  to  exist.  For  example,  an  iliac  dislocation 
of  the  head  of  the  femur  may  be  converted  into  a  sciatic  dislocation ;  the 
latter  would  then  be  called  a  consecutive  or  secondary  dislocation,  the 
former  a  primitive  or  primary  one. 

Causes. — The  predisposing  causes  of  dislocation  are  relaxed  or  stretched 
ligaments,  muscles  weakened  by  paralysis  or  atrophy,  old  teai's  in  the 
ligamentous  capsule,  and  imperfections  in  the  socket  from  either  accident 
or  disease,  and  such  relation  of  the  normal  articular  surfaces  and  liga- 
ments as  will  readily,  permit  displacement.  The  greater  the  normal 
freedom  of  motion,  and  the  more  exposed  the  joint  is  to  accidental  blows, 
the  greater  is  the  tendency  to  suffer  dislocation.  Hence  the  preeminent 
frequency  of  luxations  of  the  head  of  the  humerus.  Dislocations  at  the 
elbow  occupy  in  point  of  frequency  the  position  next  to  dislocations  at  the 
shoulder,  which  are  the  commonest  of  all  luxations.  Certain  positions  of 
the  bones  at  the  moment  of  receipt  of  injury  tend  to  allow  the  occurrence 
of  dislocation.  Thus  a  blow  on  the  chin  is  more  apt  to  dislocate  the  jaw 
if  the  mouth  is  open  at  the  time ;  so  axillary  luxation  of  the  head  of  the 
humerus  is  more  readily  produced  when  the  arm  is  abducted  and  elevated. 

The  exciting  causes  of  dislocations  are  external  violence  and  muscular 
contraction.  The  strength  of  the  ligaments  surrounding  the  joint  and 
their  disposition  in  relation  to  the  direction  of  the  applied  force  will  often 
determine  the  direction  of  the  dislocation  and  also  the  character  of 
the  injury;  that  is,  whether  it  shall  be  a  fracture  or  a  dislocation,  or 
both ;  for  violence  will  usually  either  break  or  luxate,  according  as  the 
force  drives  the  bone  toward  the  weak  or  strong  portions  of  its  liga- 
mentous capsule.  External  violence  may  exert  itself  directly  upon  or 
near  to  a  bone  or  joint,  or  indirectly  as  when  applied  at  a  distant  point  or 
extremity  of  a  bone  or  limb,  the  intervening  bone  or  bones  and  their 
attachments  acting  upon  the  principle  of  one  or  other  of  the  classes  of 
levers  to  produce  tlie  luxation.  Thus  a  fall  upon  one  foot  whilst  the  body 
is  in  an  erect  posture  may  produce  a  dislocation  of  the  knee  or  hip,  and 
a  case  is  recorded  where  a  blow  of  the  fist  upon  the  upper  portion  of  the 
humerus  produced  a  dislocation  of  the  head  of  that  bone  from  its  articular 
cavity.  Likewise,  twisting  forces  are  common  causes  of  certain  disloca- 
tions, notably  those  of  the  ankle,  hip,  and  elbow.  They  are  apt  to  occur 
in  this  manner  when  one  portion  of  an  extremity  is  held  firmly  whilst 
the  other  is  given  a  rotary,  lever-like  motion,  as  when  the  foot  is  suddenly 


478     DISEASES    OF    JOINTS,    CARTILAGES    AXD    LIGAMENTS. 

caught  and  the  whole  weight  o(  the  body  is  thus  brought  to  bear  on  the 
ankle-joint,  dislocation  will  be  the  almost  inevitable  result.  It  is  most 
j)n)l)able  that  niuscle.<  fVe(iuently  lend  great  assistance  to  external  violence 
in  the  production  of  dislocation.s,  for  it  is  a  well-known  fact  that  men 
whilst  intoxicated  seldom  su.><tain  dislocations,  and  that  much  more  force 
is  required  to  produce  luxations  in  the  cadaver  than  in  the  living  body. 
Muscular  action  may  give  rise  to  dislocations  suddenly,  as  during  voluntary 
motions  or  convulsive  seizures  of  any  description,  or  in  a  more  gradual 
manner,  as  is  witnessed  in  certain  pathological  changes  in  joints,  or  a.s  a 
result,  perhaps,  combined  with  the  former,  of  chronic  contractions  or  con- 
tractures, producing  the  so-called  "spontaneous"  dislocations.  These 
causative  factors  are  all  accidental  or  pathological,  but  there  are  certain 
persons  who,  through  possession  of  loose  articulations  or  injury,  have 
developed  habitual  dislocations,  and  can  at  will  produce  and  likewise 
replace  these  deformities.  INIuscular  contraction  is  a  very  important 
element  in  the  study  of  dislocations,  for  it  may  increase  displacement, 
render  the  course  of  the  displaced  bone  to  its  present  final  position  uncer- 
tain, and  in  some  cases  greatly  increase  the  difficulty  of  reduction.  Dis- 
tention of  joints  by  fluid  renders  their  bony  elements  peculiarly  liable  to 
displacement  by  either  muscular  or  traumatic  action.  Fracture  or  unequal 
growth  of  one  of  two  parallel  bones  renders  joints  situated  at  their  ex- 
tremities prone  to  luxation,  or  even  may  directly  cause  that  accident. 

Patholocjy. — The  pathology  of  dislocations  is  of  great  interest.  In 
incomplete  dislocations  little  change  is  to  be  noted  ;  the  ligaments  are 
stretched  but  not  usually  torn  and  ecchymoses  may  be  })resent  in  and  about 
the  joint,  but  seldom  does  any  momentous  damage, or  impairment  of  func- 
tion result.  Complete  dislocations,  on  the  other  hand,  nearly  always  pre- 
sent tearing  of  ligaments,  surrounding  tendons,  and  muscular  attachments, 
particularly  those  having  origin  from  or  insertion  into  the  capsule  itself. 
If  the  dislocation  be  typical  there  is  apt  to  be  quite  limited  tearing  of  liga- 
ments, but  where  extensive  laceration  has  taken  place  the  resulting  de- 
formity will  usually  be  irregular.  The  capsule  of  a  dislocated  joint  need  not 
of  necessity  be  ruptured,  but  may  be  entirely  stripped  from  its  bony  attach- 
ments. In  complete  luxations  of  hinge-joints  the  ligaments  are  frequently 
merely  stretched,  but  such  displacements  of  ball-and-socket  articulations 
are  always  attended  with  laceration  of  the  capsule.  This  rent  most  fre- 
quently consists  of  a  linear  slit  through  w'hich  the  head  of  the  bone  has 
been  shot.  It  is  situated,  as  a  rule,  near  the  rim  of  the  glenoid  cavity  in 
the  shoulder  and  in  the  hip  at  the  acetabular  edge.  A  knowledge  of  the 
probable  location  of  this  rent  is  of  utmost  importance  in  reduction. 

The  luxated  bones  are  apt  to  render  more  or  less  damage  to  sur- 
rounding structures,  and  muscles,  nerves,  arteries,  fascia  and  skin,  either 
or  all,  may  sustain  injury  thereby.  They  may  be  stretched,  bruised, 
or  torn,  the  latter,  in  cases  of  arteries  such  as  the  popliteal  at  the  knee  or 
the  axillary  at  the  shoulder,  being  most  formidable  complications. 
Modern  surgery  has  rendered  open  dislocations,  as  those  involving  com- 
municating lesion  of  the  skin  or  mucous  membrane,  of  practically  the 
same  pathological  significance  as  the  closed  variety.  In  voluntary 
muscular,  also  in  certain  pathological  dislocations,  the  ligaments  are 
simply  stretched  and  surrounding  structures  are  not  of  necessity  injured. 
If  the  joint  is  quickly  restored  to  its  normal  relations  by  reduction  and 
maintained  at  rest  for  the  requisite  time,  the  injured  ligaments  and  other 
structures  quickly  regain  their  normal  condition,  although  the  joint  ma}' 
always  be  weak  and  more  liable  to  future  displacement  than  Ijefore  it 


DISLOCATIOJS'S. 


479 


received  the  primary  injury.  If,  on  the  contrary,  the  dislocated  bone 
remains  in  its  new  and  unnatural  situation  a  remarkable  series  of  phe- 
nomena take  place.     The  margins  of  the  now  unused  socket  atrophy  and 


Fig.  282. 


Old  unreduced  suprapubic  dislocation  of  the  hip.     (Cooper.) 

disappear,  it  becomes  rdore  shallow,  and  finally  is  obliterated  by  bone  and 
fibrous  material.  This  process  will  occupy  in  different  cases  times  varying 
from  a  few  months  to  many  years,  and  cases  are  upon  record  where  no 


Fig.  283 


Fig.  284. 


False  joint  resulting  from  unreduced  dislocation  of  femur.     (Cooper.) 

especial  changes  had  occurred  'after  a  lapse  of  ten  years  and  it  is  to  be 
presumed  that  in  these  cases  no  change  would  ever  have  taken  place. 
Where  the  socket  thus  remains  the  synovial  membranes  and  cartilages 


480    DISEASES    OF    JOINTS,    CARTILAGES    AND    LIGAMENTS. 

have  been  preserved  and  have  resisted  atrophic  influences.  The  dislodged 
head  of  the  bone  meanwhile  has  created  a  new  socket  or  cup-shaped 
depression  for  itself  by  pressure,  atrophy  and  condensation  of  the  struc- 
tures upon  which  it  rests.  The  new  socket  will,  in  time,  have  raised 
edges,  be  lined  with  eburnated  bone-like  or  fibrous  material,  which  some- 
times becomes  covered  with  a  membrane  resembling  true  joint  or  synovial 
membrane,  which  secretes  a  lubricating  fluid  having  many  of  the 
physical  attributes  of  true  synovial  secretion.  A  species  of  capsule  may 
even  envelop  the  new  joint  in  course  of  time.  The  head  of  the  bone 
usually  undergoes  some  flattening  and  atrophy,  but  may  remain  un- 
changed. The  formation  of  a  new  joint  is  rapid  in  children  but  occupies 
years  for  its  completion  in  any  save  the  most  youthful  adults.  By  these 
natural  resources  very  fair  function  of  a  limb  may  be  regained,  even  if 
the  luxation  continue  unreduced  and  unsightly  deformity  remains.  The 
pathological  significance  of  inflammation  about  dislocations  is  very  great, 
for  by  its  means  vessels  and  nerves  are  apt  to  form  adhesions  to  the  dis- 
placed bone  extremity,  which  may  give  rise  to  rupture  of  those  structures 
when  attempts  are  made  at  reduction.  Inflammation  and  its  effects  may 
also  permanently  ankylose  a  joint  which  has  been  dislocated,  or  may  even, 
in  predisposed  individuals,  give  rise  to  purulent  arthritis. 
Symptoms. — The  principal  symptoms  of  dislocation  are : 

1.  Deformity. 

(a)  Absence  of  a  known  prominence. 
(6)  Unnatural  presence  or  disappearance  of  a  depression, 
(c)  Changes  in  length,  axis,  and  general  conformation. 
{d)  Swelling. 

2.  Rigidity. 

3.  Absence  of  crepitus. 

4.  Pain. 

5.  Force  not  generally  required  to  maintain  in  position  after  reduction. 
The  diagnosis  and  diflferential  diagnosis  of  luxations  cannot  be  made 

out  with  a  single  sign ;  sometimes  it  is  impossible,  even  to  the  most  expe- 
rienced, when  all  available  diagnostic  resources  are  brought  into  requisi- 
tion. In  this  section  it  is  proposed  to  describe  principally  typical  disloca- 
tions, and  not  to  enter  upon  their  differential  diagnosis,  as  that  has  already 
been  elaborated  under  Fractures. 

Deformity,  more  or  less  marked,  is  an  inevitable  accompaniment  and 
sign  of  dislocation.  The  bones  entering  the  structure  of  a  joint  are  dis- 
placed, and  hence  it  is  impossible  that  its  contour  and  appearances  should 
not  be  changed.  The  position  of  these  separated  joint  elements  is  usually 
the  same  and  typical  for  the  same  dislocation.  The  absence  of  one  ele- 
ment of  an  articulation  is  noted,  and  an  unnatural  prominence  has  made 
its  appearance  in  the  vicinity  of  the  joint,  the  axes  of  the  bones  are 
changed  from  that  of  their  normal  relation  to  each  other,  and  there  have 
occurred  various  other  changes,  as  in  the  length  and  circumference  of  the 
limb.  Certain  attitudes,  which  will  be  described  under  Special  Disloca- 
tions, are  significant  of  particular  dislocations. 

The  swelling  which  is  apt  rapidly  to  supervene  when  displacement  has 
occurred  is  not  usually  so  great  as  to  prohibit  diagnosis,  although  not  in- 
frequently this  symptom  may  entirely  mask  the  true  natui-e  of  the  injury. 
Strong  pressure  with  the  fingers  or  hand,  or  an  elastic  bandage  for  a  few 
moments,  may  so  dissipate  infiltration  that  salient  prominences  and  land- 
marks, or  even  all  portions  of  the  affected  bones,  may  be  made  out.  This 
failing,  the  judicious  use  of  a  well-tempered  exploring  needle  may  determine 


DISLOCATIONS.  481 

relative  positions.  When  swelling  has  come  on  with  great  rapidity,  and 
circulation  has  ceased  in  the  distal  distribution,  rupture  of  the  main  artery- 
most  probably  has  complicated  the  original  injury.  Preternatural  rigidity 
or  loss  of  function  also  usually  accompanies  dislocation.  Separated  joint 
surfaces,  as  a  rule,  have  the  same  relation  to  each  other  in  the  same  dis- 
location, and  are  held  firmly  and  rigidly  in  that  position  unless  great 
laceration  of  ligaments  or  profound  shock  also  be  present,  when  the  con- 
trary, or  even  extreme  mobility,  may  substitute  this  symptom.  Immo- 
bility is  rarely  absolute,  and  some  degree  of  motion  can  usually  be  elicited, 
which  is  limited  by  a  more  or  less  elastic  check  imparted  by  the  remaining 
portions  of  ligaments  and  the  resistance  of  soft  parts  surrounding  the 
dislocated  bone.  If  the  injury  is  also  associated  with  fracture,  rigidity 
will  not  usually  be  present.  Utmost'  caution  must  be  used  in  diagnosing 
dislocations,  in  patients  whose  age  permits  the  possibility  of  epiphyseal 
fractures,  to  distinguish  the  former  from  the  latter,  as  both  possess  points 
of  great  resemblance. 

The  corresjDonding  bones,  joints,  and  regions  of  both  the  injured  and 
sound  side  of  the  body  should  always  be  compared,  and  the  two  hands 
made  to  examine  synchronously  and  contrast  the  corresponding  depres- 
sions, prominences,  and  "  landmarks  "  of  the  two  sides.  If  this  be  made 
a  rule  of  practice  and  procedure,  many  an  incorrect  diagnosis  arising  from 
inappreciation  of  the  peculiar  topography  of  the  patient  under  considera- 
tion will  be  avoided,  and  still  other  cases  will  thus  be  quickly  robbed  of 
their  diagnostic  difficulties. 

True  crepitus  cannot  be  developed  in  a  case  of  dislocation  unaccom- 
panied by  fracture,  but  it  is  likewise  true  that  this  sign  cannot  be  devel- 
oped in  every  case  of  fracture.  Often  a  friction  sound  or  sense  can  be 
perceived  in  dislocations,  which  is  developed  when  compressed  fibrous  or 
muscular  tissues  and  the  displaced  bone  are  moved  upon  each  other,  and 
the  simple  movement  of  dry  or  otherwise  altered  synovial  membranes  is 
quite  sufficient  to  produce  this  "false  crepitus."  This  symptom  is  unusual 
in  veiy  recent  luxations,  and  does  not  often  make  its  appearance  until 
one  or  more  days  have  elapsed  since  the  occurrence  of  injury;  but  fric- 
tion of  a  torn  ligament  may  give  rise  to  it  at  any  period  of  the  case. 
Dislocation  crepitus  is  much  more  obscure  than  is  that  of  fracture,  unless 
the  latter  happen  to  be  deeply  situated  or  when  inflammation  has  caused 
softening  of  the  disrupted  surfaces.  A  dislocation  complicated  by  a  small 
fracture,  as  of  a  chip  from  an  acetabular  rim  or  a  torn-ofi*  tuberosity,  may 
present  either  or  both  forms  of  crepitus.  Such  injuries  are  often  impos- 
sible of  more  exact  diagnosis  than  supposition. 

Pain  in  dislocations  is  frequently  more  unbearable,  and  of  a  dull 
throbbing  or  stretching  and  tearing  variety  than  is  the  case  with  that  of 
fractures.  If  nerves  have  been  pressed  upon  or  torn,  tingling,  numb- 
ness, or  anaesthesia  and  paralysis  of  their  distributions  will  be  tempo- 
rarily or  permanently  present,  according  to  the  degree  of  nerve  injury 
sustained.  Muscles  are  placed  upon  the  stretch,  and  the  bone  extremity 
is  probably  pressing  powerfully  upon  surrounding  structures — an  aggre- 
gate of  causes  quite  sufficient  to  account  for  the  very  marked  subjective 
symptoms  of  which  cases  of  dislocation  so  often  pathetically  complain. 

Unless  taken  in  conjunction  with  all  the  other  signs  of  dislocation 
retained  position  after  reduction  is  a  symptom  of  no  great  moment.  It 
is  a  fact  that  dislocations  when  reduced  customarily  remain  in  position, 
but  the  contrary  is  as  often  true  if  there  has  been  great  laceration  of  liga- 

BI 


482    DISEASES    OF    .lOINTS,    CARTILAGES    AND    LIGAMENTS. 

ments  or  soft  parts,  whilst  many  fractures,  notably  certain  ones  about  the 
wrist,  will  retain  their  position  perfectly  when  set  or  reduced. 

Open  or  coni|)oun(l  di^^locations  present  very  little  difficulty  in  diagnosis, 
for  their  ehanu-ter  is  easily  cleared  up  by  the  opportunity  for  direct  ex- 
amination which  is  afforded  during  the  necessary  process  of  treatment. 

Luxations  complicated  by  fracture  have  been  discussed  under  the  latter 
heading.  They  are  injuries  of  much  gravity  as  regards  diagnosis,  treat- 
nent,  and  prognosis. 

Pko<;nosis. — The  general  prognosis  of  a  given  dislocation  is  favorable 
or  unfavorable  in  direct  ratio  to  its  complications.  Simple  luxations 
promptlv  and  completely  reduced  and  ke)>t  at  rest  for  the  requisite  length 
of  time  practically  never  of  themselves  endanger  life,  limb,  or  functi(m  ;  the 
slit  in  the  capsule  firmly  heals,  the  displaced  surrounding  tissues  quickly 
return  to  their  former  condition,  and  little  save  some  swelling  and  perhaps 
some  pain  and  stiflhess  remains  to  remind  the  patient  of  his  recent  accident. 
But  this  pain  and  stiffness — usually  the  result  of  the  necessary  immobiliza- 
tion of  the  joint  to  insure  healing  of  the  torn  structures — may  continue  for 
a  long  time  or  even  in  exceptional  instances  lead  to  i)ermanent  disability. 
Some  weakness  or  atrophy  may  also  follow  simple  displacements ;  this  prob- 
ably being  due  not  only  to  inaction  of  the  muscles  but  also  in  part  to  stretch- 
ing or  bruising  of  the  proximate  nerves  or  muscles.  Atmospheric  changes 
are  apt  to  have  a  forecast  in  the  painful  stiffness  which  the  injured  parts 
may  assume  before  a  change  of  weather,  for  perhaj)S  even  years  after  dis- 
location. Much  also,  in  all  forms  of  dislocations,  depends  upon  the  par- 
ticular joint  involved,  the  degree  of  the  displacement,  the  condition  of 
health  and  the  reparative  powers  of  the  individual,  the  means  employed 
for  reduction,  and  the  time  af\er  accident  when  treatment  was  instituted. 

Thorough  reduction  may  be  rendered  impossible  by  a  portion  of  liga- 
ment or  mu.scle  occupying  the  joint  cavity,  and  preventing  the  replace- 
ment or  retention  of  the  dislocated  bone. 

Secondary  or  recurrent  dislocations  are  rarely  of  special  danger,  but 
the  prospects  of  permanent  cure  are  extremely  slight.  When  luxations 
are  complicated  by  rupture  of  the  main  artery  of  an  extremity  the 
prognosis  becomes  most  grave,  and  loss  of  the  limb  or  even  of  life  is  the 
common  result.  Torn  nerves,  muscles,  or  tendons  are  not  of  such  serious 
import,  as  they  can  often  be  restored  to  functional  activity  i)y  operation. 

Open  dislocations  have  been  robbed  of  most  of  their  former  terrors  and 
•dangers  bv  modern  wound  treatment,  but  they  will  always  be  much  more 
serious  injuries  than  simple  luxations,  from  their  liability  to  become  in- 
fected, if  they  can  be  guarded  from  this  latter  complication  the  chances 
of  saving  the  joint  and  ultimately  restoring  it  to  usefulness  are  very  good. 

Old  dislocations  or  recent  ones,  which  it  is  found  impossible  to  reduce, 
are  not  to  be  prognosticated  so  unfavorably  as  might  at  first  sight  seem 
necessary,  for  often  by  the  formation  of  false  sockets  and  articulations 
much  of  the  functional  activity  of  a  limb  may  be  restored,  which  use- 
fulness is  prone  to  increase,  not  to  decrease  as  time  goes  on.  But,  un- 
fortunately, pressure  exerted  by  the  bone  in  its  new  location  may  cause 
much  distress  or  danger.  The  degree  of  disability  in  these  ancient  dis- 
locations will  depend  largely  upon  the  nature  of  the  joint  involved.  Thus 
ball-and-socket  joints  when  unreduced  give  rise  to  much  less  interference 
with  function  than  do  similar  conditions  in  hinge  joints,  and  even  one 
variety  of  dislocation  may  give  rise  to  less  disability  than  another  at  the 
same  articulation.  Thus,  deformity  is  much  less  in  a  sciatic  dislocation 
at  the  hip  or  a  subglenoid  at  the  shoulder  than  is  the  deformity  resulting 


DISLOCATIONS.  483 

from  other  dislocations  of  the  corresponding  bones.  Attempts  to  reduce 
old  dislocations  are  always  serious  undertakings,  from  the  danger  of  rup- 
turing arteries  which  may,  through  inflammatory  action,  have  become 
attached  to  the  displaced  bone  or  its  fibrous  surroundings.  Especially  is 
this  danger  salient  in  old  luxations  of  the  humerus. 

Treatment. — Spontaneous  reduction  occasionally  takes  place,  more 
especially  in  partial  luxations  and  in  those  of  the  shoulder.  This  desid- 
eratum may  be  brought  about  by  movement  during  sleep,  falls,  or  after 
unsuccessful  attempts  at  reduction  have  failed  of  their  purpose,  but  have 
so  broken  up  adhesions  that  the  force  of  muscular  contraction  or  volun- 
tary motion  afterward  draws  the  displaced  bone  into  position. 

Except  in  certain  complicated  cases,  treatment  of  acute  dislocations 
should  always  be  instituted  at  the  earliest  possible  oi^portunity,  and  the 
earlier  reduction  is  attempted  just  so  much  more  readily  can  it  be  attained. 

There  is  often  a  period  lasting  a  short  time  after  the  accident  during 
which  the  muscles  have  not  begun  to  contract,  and  at  this  time  some  dis- 
locations are  most  readily  reduced.  The  writer  once  had  opportunity  to 
prove  this  assertion  in  the  case,  of  a  fellow  swimmer  who  sustained  a  sub- 
coracoid  dislocation  of  the  humerus  by  his  arm  being  forced  upward  and 
outward  in  striking  the  water  whilst  diving.  It  was  reduced  with  utmost 
ease  by  manipulation  before  more  than  one  or  at  most  two  minutes  had 
elapsed.  No  especial  care  was  taken  of  this  member  afterward,  but  dislo- 
cation never  recurred.  The  indications  for  treatment  are:  1,  to  reduce 
the  dislocations ;  2,  to  secure  firm  repair  without  inflammation,  and  3,  to 
restore  function. 

Eeductiou  is  to  be  accomplished  by  constitutional  relaxing  measures, 
and  by  manipulation.  Mechanical  force  is  never  required  or  permissible 
in  recent  luxations.  Prolonged  painful  efibrts  to  reduce  a  dislocation 
should  never  be  made,  and  relaxation  by  ether  should  be  secured  in  all 
rigid  dislocations  of  the  larger  joints  ;  also  in  case  of  any  joint  should  it 
resist  our  first  few  efforts  or  give  rise  to  excessive  pain  upon  motion. 

The  primary  stage  of  ether,  or  some  abruj^t  question  or  accusation  put 
to  the  patient,  may  occasionally  direct  attention  from  the  injured  parts 
and  permit  the  surrounding  muscle  to  be  surprised  and  the  joint  reduced 
by  a  rapid  manipulation,  but,  usually,  an- 
sesthesia  to  the  stage  of  profound  relaxation  Fig.  285. 

must  be  attained  before  manipulation  can 
properly  be  applied  and  reduction  eflected. 

Reduction  made  without  the  addition  of 
mechanical  force  to  the  ordinary  powers  of 
the  surgeon  constitutes  replacement  by  ma- 
nipulation, which  method  is  always  prefer- 
able to  any  other.  But  in  certain  cases 
the  hands  of  an  assistant  may  be  addi- 
tionally employed  or  a  better  hold  upon 
the  part  obtained  by  wrapping  it  in  cloths, 
or  by  throwing  a  "  clove-hitch "  or  noose 
knot  above  some  bony  prominence,  which 
will  prevent  slipping  or  damage  by  traction  CloTe-hiteh  knot. 

upon  soft  parts. 

The  object  of  manipulation  is  to  secure  through  one  or  more  consecutive 
processes  of  extension  and  counter-extension,  rotation,  pressure,  adduction, 
abduction,  flexion  or  extension,  the  replacement  of  the  dislocated  bone. 
By  these  processes  relaxation  of  some  structures  and  tension  of  others  is 


484     DISEASES    OF    JOINTS,    CAKTILAGES    AND    LIGAMENTS. 

attained  which  either  assist,  permit  others  to  assist,  or  are  prevented  from 
hindering  the  return  of  the  bone  to  its  socket  by  the  route  of  exit.  From 
this  it  will  be  seen  that  to  reduce  luxations  by  manipulation  an  accurate 
comprehension  of  the  mechanism  of  dislocations  must  be  possessed  bv  the 
surgeon  who  may  be  called  upon  to  replace  them.     Bade  manipulation  if 


Fio.  286. 


Clove-hiteh  knot  aj)plie(l.     (Agxew.j 
Fir..  2s7. 


Noose  knot. 

persisted  in  may  often  accomplish  reduction  in  the  hands  of  ignorant  per- 
sons, but  exact  anatomical  knowledge  is  vastly  safer,  more  satisfactory, 
and  successful.  The  surgeon  should  be  familiar  with  those  motions  best 
calculated  to  relax  the  bone  capsule,  or  to  remove  other  obstructions,  and 
to  bring  into  play  such  muscles  or  ligaments  as  will  assist  him  in  his  en- 
deavors to  replace  the  bone.  Sometimes  a  rocking  motion  combined  with 
manipulation  will  insinuate  an  obstinate  bone  into  its  proper  position. 
Manipulation  to  prove  successful  must  be  applied  systematically,  and  the 
sequence  of  its  various  objects  must  follow  in  regular  order.  Thus, 
obstructive  tension  is  first  to  be  overcome.  Then  the  bone  is  to  be 
dislodged  and  gotten  opposite  the  capsule  rent  and  finally  forced  into  posi- 
tion ;  which  last  two  procedures  are  often  accomplished  through  making 
portions  of  ligaments,  etc.,  act  as  pulleys  or  levers.  As  the  capsule  rent 
is  made  by  pressure  of  the  head  of  a  bone,  hence  the  lesion  is  always  in 
the  direction  of  dislocation,  and  the  rule  is  always,  if  possible,  to  return 
the  bone  in  the  exact  direction  of  dislocation.  If  only  a  slit  exists  in  the 
capsule  that  ligament  must  be  relaxed  to  permit  reduction,  but  unless  a 
flap  has  been  torn  from  one  edge  the  capsule  will  never  prevent  reduction 


DISLOCATIONS.  485 

by  occupying  the  normal  position  of  the  displaced  bone.  The  existence 
of  an  obstructive  flap  is  an  extremely  unfortunate  occurrence,  and  one 
which  nothing  short  of  an  operation  will  relieve  in  some  cases.  Reduc- 
tion will  sometimes  be  further  obstructed  by  muscles  or  tendons  slipping 
over  or  under  the  dislocated  head.  For  these  complications,  as  when  the 
metacarpal  bone  of  the  thumb  slips  under  a  head  of  the  flexor  tendon, 
nothing  short  of  division  of  the  restricting  band  will  suffice,  that  the 
reduction  may  be  completed. 

If  swelling  interferes  with  reduction  we  should  be  content  to  wait  until 
it  in  part  or  wholly  subsides.  This  takes  place  Avith  rapidity,  and  little 
is  lost  by  the  pursuance  of  such  a  course. 

But  cases  will  occasionally  be  encountered  in  which  manipulation  will 
fail,  or  where  anaesthesia  is  refused  or  inadmissible,  and  to  these  we  will 
be  driven  to  apply  the  application  of  force.  This  agent  is  brought  into 
action  by  means  of  extension  and  counter-extension,  energetic  rotation, 
and  by  direct  or  indirect  pressure,  or  one  or  all  of  these  measures  in  con- 
nection with  manipulation.  The  required  force  must  gain  access  to  the 
limb  through  certain  mechanical  attachments.  If  bandages  or  cloths  are 
used  for  this  purjDose  they  should  previously  be  moistened,  for  in  that  con- 
dition they  are  less  liable  to  slip. 

Clove  hitches,  noose  knots,  elastic  bands,  or  the  metal  attachment  plates 
of  Levis,  which  are  shown  under  Refracture  of  Deformed  Union  After 
Fracture,  can  be  used  for  this  purpose.  Great  caution  must  be  observed 
that  pressure  or  traction  be  not  made  upon  the  skin  or  soft  parts,  but  that 
bone  extremities  are  made  the  points  of  resistance.  By  these  means  in- 
definite extension  and  power,  limited  only  by  the  strength  of  the  distal 
bone,  may  be  secured.  Forcible  reduction  should  be  made  to  simulate 
the  motions  of  manipulation  as  nearly  as  possible ;  but  if  this  cannot  be 
attained  then  the  force  should  be  applied  in  the  direction  which  will  bring 
the  head  of  the  bone  directly  to  the  socket,  or  to  such  proximity  to  it 
that  lateral  pressure  or  rotation  will  complete  the  reduction. 

The  power  must  be  applied  gradually,  steadily,  and  with  the  greatest 
judgment ;  a  rocking  motion  may  be  superadded  at  times  with  benefit  to 
force  the  dislocated  bone  from  entanglements,  or  by  chance  to  slip  it  into 
the  socket. 

Gradual  continuous  extension  by  elastic  bands  or  weights  acting  over 
a  pulley  often  proves  of  great  utility.  Up  to  fifty,  or  more,  pounds  of 
weight  may  thus  be  employed,  but  it  will  be  found  that  lesser  weights 
acting  for  a  long  time  will  accomplish  more  than  will  greater  amounts 
for  a  shorter  time.  Compound  and  other  pulleys,  until  recently  so  much 
in  vogue,  are  to  be  unequivocally  condemned  for  recent  luxations,  and 
only  most  rarely  can  there  ever  arise  necessity  or  indications  for  them  in 
any  form  of  dislocation.  Ansesthesia  is  as  beneficial  and  requisite  during 
the  reduction  of  displacements  by  forcible  means  as  in  manipulation. 

Force  is  to  be  applied  as  follows  :  1.  The  power  is  to  be  exerted  in  a 
proper  direction.  2.  It  must  not  be  applied  in  a  spasmodic  or  violent 
manner,  but  continuously,  and  with  a  gradual  increase  of  amount.  3.  The 
pai't  must  be  rotated  and  rocked  in  all  directions  to  free  the  head  of 
the  bone  from  entanglement  or  adhesions.  4.  When  resistance  of  muscles 
has  been  sufficiently  overcome  to  permit  the  head  of  the  bone  to  reach 
the  level  of  the  cavity  from  which  it  has  been  replaced,  an  adroit  move- 
ment of  the  part  must  be  made  by  the  hands  of  the  surgeon  toward  that 
cavity,  whilst  at  the  same  instant  the  extending  force  should  be  relaxed 
by  an  assistant. 


486     DISEASES    OF    JOINTS,    CARTILAGES    AND    LIGAMENTS. 

Should  even  these  measures  fail,  then  will  arise  the  advisability  of  insti- 
tuting such  operative  measures  as  subcutaneous  or  open  division  of  the 
restricting  tissues,  or  even  of  the  neck  of  the  dislocated  bone  itself;  the 
excision  of  its  head  or  of  the  whole  joint,  or,  finally,  of  amputation. 

A  dislocation  is  known  to  have  been  reduced  when  the  articulation 
assumes  its  normal  contour  and  functions,  and  by  the  direction  of  the 
axis  of  the  limb  or  the  elements  of  the  joint.  Tiie  fact  is  frequently  an- 
nounced by  the  before-mentioned  moist  or  mutHed  snap.  The  dangers 
incident  to  the  application  of  force  are  proportionate  to  the  presence  and 
nature  of  adhesions,  and  to  the  amount  applied. 

After  being  reduced  the  joint  must  be  kept  at  rest  by  means  of  splints, 
bandages,  or  apparatus  for  a  few  days  or  weeks,  according  to  the  severity 
of  the  dislocation,  the  joint  involved  and  the  nature  of  complications. 

At  the  expiration  of  this  time  passive  motion  is  begun,  and  shortly 
afterward  active  movements,  or  customary  occupations,  may  be  resumed. 
But  movements  in  the  direction  of  the  former  capsule  tear  should  be 
avoided  for  as  long  a  time  as  possible.  If  these  precautiims  are  not  con- 
sidered the  risk  of  recurrence  or  of  establishing  an  "  habitual  dislocation  " 
becomes  very  great.  Electricity,  massage,  hot  and  cold  douches,  and 
injections  of  strychnia  will  prove  of  benefit  if  muscles  have  lost  their 
power.  Should  inflammatory  reaction  occur  its  symptoms  are  to  be  met 
with  the  usual  means. 

Treatment  of  Old  Dislocations. 

Much  that  has  already  been  said  applies  equally  to  the  treatment 
of  old  dislocations.  For  reasons  already  stated  it  is  justifiable  to 
make  judicious  attempt  at  reduction  of  any  dislocation,  no  matter  what 
may  be  its  age.  In  this  variety  of  dislocation  passive  motion,  poulticing, 
massage  and  extension  should  be  kept  up  for  days  or  weeks  before  an 
attempt  at  reduction  should  be  undertaken.  Any  restricting  tissues 
should  be  divided  some  time  previously.  Manipulation,  even  if  it  does 
not  accomplish  its  ulterior  object,  frequently  gives  the  patient  a  wider 
range  and  ability  of  motion  than  he  had  before.  Attempts  to  break  up 
or  reduce  old  dislocations  are  always  to  be  undertaken  with  the  full 
knowledge  of  both  surgeon  and  patient  of  the  great  risks  to  be  encoun- 
tered in  all  such  operations. 

The  most  common  accidents  attending  the  modern  reduction  of  old  dis- 
locations are  rupture  of  vessels  and  nerves,  fracture,  and  rendering  the 
injury  open  or  compound  by  giving  way  of  the  skin.  Rupture  of  vessels 
is  almost  exclusively  limited  to  arteries,  and  of  the  latter,  principally  to 
the  axillary,  and  are  most  fatal  accidents  under  any  form  of  treatment. 
Their  occurrence  is  recognized  by  the  sudden  formation  of  a  pulsating 
tumor  in  the  neighborhood  of  the  old  injury.  Exceptionally  the  artery 
does  not  rupture  until  several  days  after  the  attempt  at  reduction,  or  an 
aneurism  may  form  either  with  rapidity  or  otherwise.  Gangrene  of  the 
limb  may  follow  pressure  upon  or  laceration  of  vessels. 

Fracture,  if  it  take  place  close  to  the  dislocated  head  may  prove  of 
more  benefit  than  injury  by  forming  an  artificial  joint  and  save  subsequent 
recourse  to  operation  for  the  same  purpose.  Recoveries  have  taken  place 
in  all  varieties  of  these  accidents.  Torturing  neuralgia,  persistent  cedema, 
aneurism,  varix  and  gangrene  are  possible  sequelae  of  unreduced  luxations 
or  of  efforts  made  for  their  relief. 

The  treatment  of  open  or  compound  dislocations  has  been  discussed 
under  Wounds  of  Joints. 


SPECIAL    DISLOCATIONS, 


487 


Special  Dislocations. 


Dislocations  of  the  Vertebrce. 

Dislocations  of  the  vertebrae  unaccompanied  by  fracture  are  injuries  of 
rarity.  The  ultimate  effect  of  almost  all  casualties  of  this  nature  is 
lethal ;  most  commonly  immediately,  but  exceptionally  death  is  postponed 
for  mouths.  Some  cases  recover.  The  seat  of  lesion  is  most  commonly 
in  the  cervical  region,  less  frequently  in  the  dorsal,  and  never,  so  far  as 
surgical  history  goes,  in  the  lumbar  region.  The  most  common  disloca- 
tion is  that  of  the  axis.  The  cervical  region  is  predisposed  to  these  acci- 
dents because  of  its  range  of  motion  and  freeness  of  articulation. 

Most  dislocations  of  the  cervical  spine  are  simple  or  uncomplicated,  but 
may  be  complete  or  incomplete.  The  region  bounded  by  the  fourth  and 
sixth  vertebrffi  is  most  vulnerable.  Any  variety  of  displacement  may 
injure  the  cord,  rupture  its  vessels,  or  give  rise  to  subsequent  inflamma- 
tion or  effusion. 

The  treatment  of  spinal  dislocations  consists  of  reduction,  if  feasible, 
and  subsequent  care  of  bladder,  rectum,  and  surfaces  exposed  to  pressure, 
as  in  fracture  complicated  by  cord  injury.  The  water  or  air-bed  and 
extreme  cleanliness  will  likewise  be  found  of  great  utility  to  prevent 
pressure  necrosis. 

Dislocations  of  the  Cervical  Vertebrce. 

Dislocations  below  the  axis  are  usually  forward  ;  that  is,  all  the  vertebrae 
above  the  seat  of  displacement  are  thrown  forward,  but  lateral  or  rotary 

dislocations  are  not   unknown  in 
Fig.  288.  this  region. 

These  luxations  are  caused  by 
indirect  violence  bending  or  twist- 
ing the  neck.  If  complete,  the  pos- 
terior common  vertebral,  also  the 
lateral,  ligaments  are  torn. 

Save    in    certain    well-marked 


Bilateral  dislocation  forward  of  fifth   cervical 
vertebra.     (Atres.) 


Dislocation  ot    cervical  vertebrae  by 
flexion;  median  section.  (Bryant.) 


488     DISEASES    OF    JOINTS.    CARTILAGES    AND    LIGAMENTS. 

cases  exact  diagnosis  is  very  difficult  in  dislocations  of  the  cervical  spine. 
The  head  is  bent  rigidly  on  the  breast  in  forward,  and  in  the  opposite 
direction  in  backward  dislocations.  A  prominence  or  depression,  accord- 
ing to  the  direction  of  the  dislocation,  may  sometimes  be  noted  by  a  finger 
carried  into  the  pharynx.  If  the  injury  he  above  the  origin  of  the  phrenic 
nerves,  death  is  usually  instantaneous. 

Treatment  consists  of  extension  by  hands  placed  upon  the  chin  and 
occiput  and  counter-extension  by  ])ulling  upon  the  patient's  feet ;  or  by 
means  of  a  folded  sheet  drawn  over  the  shoulders  combined  with  manip- 
ulations calculated  to  disengage  the  luxated  vertebrte,  and  direct  pressure 
applied  at  the  same  time  to  the  neck  and,  perhaps,  through  the  pharynx. 

A  tlo-axo  id  Dislocations. 

Alto-axoid  dislocations  come  next  in  order  of  frequency.  Three  varie- 
ties exist:  the  odontoid  process  of  the  axis  may  be  fractured  and  thus 
permit  dislocation  of  that  vertebra  backward  and  crushing  of  the 
cord ;  the  odontoid  ligament  or  some  fibres  of  its  transverse  portion 
may  be  torn  and  permit  the  odontoid  process  of  the  axis  to  slip  beneath 
it;  or  the  atlas  may  be  rotated  upon  the  axis  until  the  articular  ligaments 
rupture  and  permit  the  former  bone  to  rest  obliquely  upon  the  latter. 
These  lesions  result  from  force  applied  to  the  head,  from  falls,  blows,  and 
twists  ;  whilst  the  presence  of  vertebral  caries  greatly  predisposes  to  them. 
The  symptoms  and  consequently  the  exact  diagnosis  of  these,  as  of  other 
cervical  dislocations,  are  vague  and  unsatisfactory.  They  usually  prove 
rapidly  fatal,  and  great  precaution  must  be  observed  in  the  treatment,  as 
instant  death  is  liable  to  follow  even  trivial  attempts  at  reduction,  from 
injury  to  the  cord  by  pressure  from  the  odontoid  process.  Nevertheless, 
it  is  our  duty  to  attempt  such  reduction  by  traction  (as  above)  in  the 
line  of  the  spinal  column,  manipulation,  and  direct  pressure.  If  success 
attends  the  surgeon's  eflforts  care  must  be  taken  to  retain  the  head  in  the 
proper  position  by  pillows  or  other  means. 

Occipito-atloid  Dislocations. 

Occipito-altoid  dislocations  are  occurrences  of  great  rarity  and  fatality, 
being  due  to  great  violence  tearing  the  condyles  of  the  occipital  bone 
from  the  articulating  cavities  of  the  atlas. 

Dislocations  of  (he  Dorsal  Vertebrce. 

Dislocations  of  the  dorsal  vei'tebraj  occur,  but  usually  are  accompanied 
bv  fracture,  because  of  the  great  force  required  to  lacerate  the  powerful 
ligaments  and  joints  which  are  to  be  found  in  that  region.  They  are 
caused  by  violent  flexions  or  rotations  of  the  body.  The  diagnosis  is  self- 
evident  and  precisely  similar  to  that  of  fracture  in  the  same  region,  and 
treatment  consists  of  application  of  the  same  measures  as  for  other  ver- 
tebral displacements,  except  that  continuous  extensicm  and  counter-exten- 
sion should  form  a  more  prominent  feature  of  after-treatment. 

Dislocations  of  the  lumbar  region  without  fracture  are  unknown.  They 
require  no  separate  consideration. 


SPECIAL    DISLOCATIOXS.  489 


Dislocations  of  the  Ribs  from  the  Vertebral  Column. 

A  few  cases  of  this  variety  of  injury  appear  in  surgical  history  of  times 
now  remote ;  none  have  been  recorded  during  the  past  forty-four  years. 
They,  as  a  rule,  accompany  terrific  lethal  traumata.  Diagnosis  is  made  by 
the  absence  of  the  head  of  the  rib  from  its  vertebral  socket,  and  treatment 
is  to  be  supplied  by  a  broad  band  highly  encircling  the  chest. 

Dislocations  of  the   Coccyx. 

These  unusual  injuries  take  place  principally  in  women,  resulting  from 
falls,  kicks,  or  other  direct  violence,  or  during  parturient  efforts. 

Three  varieties  have  been  observed  :  forward,  which  is  most  frequent, 
backward,  and  lateral.  The  symptoms  of  the  accident  are  great  pain, 
swelling  over  the  region,  and  rectal  examination  discloses  the  displace- 
ment and  its  variety. 

The  forward  luxation  is  to  be  reduced  by  hooking  the  finger  over  it  in 
the  rectum  and  drawing  it  downward  into  position.  Beyond  manipula- 
tion and  pressure,  no  definite  rules  can  be  given  for  treating  this  form  of 
luxation.  Instant  relief  follows  replacement,  but  recurrence  is  probable. 
Old  or  inveterate  dislocations  may  demand  excision  of  the  afiected  parts. 
(See  Excision  of  Joints.) 

Dislocations  of  the  Jatv. 

This  dislocation  occurs  in  four  per  cent,  of  all  luxations.  It  may  be 
partial,  bilateral,  or  unilateral.  A  shallow  gelnoid  fossa  and  lax  articular 
ligaments  predispose  to  the  injury ;  whilst  yawning,  laughing,  sneezing, 
blows,  and  falls  are  exciting  causes.  Attempts  to  separate  the  jaws  ex- 
cessively, or  blows  upon  the  chin  whilst  the  mouth  is  open,  are  prolific 
causes  of  luxation. 

The  mechanism  of  this  dislocation  is  brought  about  by  the  internal 
pterygoid  muscles  becoming  a  fulcrum,  and  the  muscles  inserted  into  the 
chin  becoming,  as  it  were,  the  long  arm  of  a  lever,  which,  with  the  assist- 
ance of  the  external  pterygoids,  cause  the  condyles  of  the  jaw  to  press 
upon  and  rupture  the  capsular  ligaments,  and  spring  in  front  of  the  articu- 
lar eminences,  when  contraction  of  the  masseter  and  temporal  muscles 
draws  them  forcibly  upward  until  they  are  arrested  by  the  zygomatic 
arches  and  the  typical  deformity  is  produced.  Rarely  the  capsule  is  not 
torn. 

The  symptoms  are  wide  separation  and  firm  fixation  of  the  lower  jaw; 
a  vacuity  is  noticed  in  front  of  the  ear,  and  the  condyles  may  be  felt 
beneath  the  zygoma. 

A  backward  dislocation  has  been  described  in  which  the  condyles  are 
violently  forced  through  the  anterior  wall  of  the  auditory  canal.  Anaes- 
thesia is  not  required  in  the  treatment  of  this  dislocation,  which  consists 
in  the  surgeon  carefully  protecting  his  thumbs  with  strips  of  bandages, 
and  then  with  them  pressing  downward  upon  the  last  molar  tooth  upon 
each  side  of  the  jaw,  whilst,  at  the  same  time,  the  palms  and  fingers  grasp 
each  side  of  the  maxilla  externally  and  press  it  backward.  By  these 
manceuvres  the  process  of  dislocation  is  exactly  reversed  ;  tension  of  the 
internal  pterygoid  and  masseters  is  overcome  by  the  downAvard  pressure ; 
the  condyles  are  pressed  backward  into  position,  and,  upon  releasing  the 


490    DISEASES    OF    JOINTS,    CARTILAGES    AND    LrOAMENTS. 

pressure,  are  drawn  with  great  force  into  position  by  contraction  of  the 
temporal  and  masseter  muscles.  If  the  surgeon's  fingers  are  not  pro- 
tected or  removed  to  the  side  of  the  teeth  quickly,  they  are  liable  to  be 
injured  from  the  force  with  which  the  molars  are  drawn  together. 


Fig.  2vi0. 


Vu:.  291. 


Bilateral  dislocation  of  lower  jaw. 


Deformity  resulting  from  bilateral  dis- 
location of  lower  jaw.     (Asuhvrst  ) 


Unilateral  displacements  are  to  be  treated  in  a  similar  manner.  If  in 
subluxations  the  teeth  are  firmly  together,  simple  forcing  of  them  apart 
will  suffice  for  reduction. 


Fig.  292. 


Reduction  of  dislocated  jaw.     (Erichsen. 


Old  maxillary  dislocations  are  to  be  treated  as  acute  ones  first,  and,  this 
failing,  the  forcing  apart  of  the  posterior  portions  of  the  jaw  by  levers  or 
Stromeyer's  forceps,  or  even  the  excision  of  the  condyles,  is  permissible. 

After  reduction  the  jaw  must  be  kept  immobilized  for  at  least  a 
week  by  means  of  a  Barton  or  similar  bandage,  and  the  patient  fed 
principally  upon  liquids.     If  this  rule  is  neglected  there  is  great  danger 


SPECIAL    DISLOCATIONS.  491 

of  recurrence  or  of  the  establishment  of  habitual  exarticulation,  subluxa- 
tion, or  a  snapping  sound  during  eating. 

Fig.  293. 


Stromeyer's  forceps. 

Dislocations  of  the  Sternum. 

This  dislocation  is  unusual  and,  from  the  violent  nature  of  the  force 
required  to  produce  it,  has  proved  fatal  in  almost  50  per  cent,  of  cases  in 
which  it  has  occurred.  Direct  force  is  the  usual  cause.  Reduction  is 
impossible  in  most  cases,  but,  if  the  patient  survive  the  complications  he 
is  not,  as  a  rule,  incommoded  by  the  resulting  deformity.  Extension  of 
the  chest  by  bending  the  dorsal  spine  over  a  block  of  wood  or  round 
pillow  together  with  manipulation  and  moulding  may  be  tried,  and  should 
they  prove  successful  a  broad  bandage  must  highly  encircle  the  chest  for 
some  weeks  subsequently.     Anaesthesia  will  favor  replacement. 

Dislocations  of  the  Clavicle. 

I  shall  speak  of  luxations  of  the  outer  end  of  the  clavicle  as  disloca- 
tions of  the  scapula. 

Dislocations  of  the  clavicle  occur  at  the  sterno  clavicular  articulation  in 
either  a  forward,  backward,  or  upward  direction.    Dislocation  at  this  joint 
is  favored  by  a  shallow  glenoid  cavity  and 
by  the  great  range  of  shoulder  motions,  Fig.  294. 

which  indirectly  affect  the  clavicular  ar-  ^^ 

ticulation.      The   disarticulation    may  be  ) 

complete  or  incomplete. 

Hypertrophied  or  violent  movements  of 
the  shoulder  are  the  most  universal  cause, 
but  slow  dislocation  may  result  from  nature 
of  occupation  stretching  the  retaining  liga- 
ments. All  dislocations  in  this  region  are 
very  easy  of  reduction  by  proper  manip- 
ulation of  the  shoulder  and  direct  pressure  Dislocation  of  sternal  end  of 
combined,  but  are  more  than  correspond-  clavicle.  (Bryant.) 
ingly  difficult  to  retain  in  place. 

The  symptoms  are  sharp  local  pain  and  head  of  clavicle  in  new  posi- 
tion, before,  above,  or  behind  normal  situation.  In  backward  displace- 
ments aphonia  and  dysphagia  of  varying  degrees  may  be  caused  by 
pressure  of  the  dislocated  head  upon  the  trachea  and  oesophagus.  These 
latter  symptoms  rapidly  disappear  even  if  the  luxation  continues  unre- 
duced. 

Treatment  is  usually  successful  so  far  as  primary  reduction  is  concerned, 
but  recurrence  is  almost  inevitable,  and  sooner  or  later  becomes  habitual 


492     DISEASES    OF    JOINTS,    CARTILAGES    AND    LIGAMENTS. 

or  permanent.  The  head  of  tlie  bone  may  be  excised  if  it  produces  dan- 
gerous or  painful  pressure  symptoms.  In  reduction  the  shoulder  must  be 
drawn  outward  and  forward  in  forward  dislocations  ;  outward  and  back- 
ward in  backward,  and  upward,  or  upward  and  outward,  in  upward 
dislocations.  By  these  shoulder  manipulations  in  all  three  varieties 
the  dislocated  head  is  coaxed  to  the  margin  of  its  socket,  when  direct 

Fig.  295. 


Dislocation  upward  of  tlie  sternal  end  of  the  clavicle.     (R.  W.  Smith.) 

pressure  and  mouldino;  are  applied,  and  the  process  is  restored  to  its 
normal  position.  When  reduced  it  must  if  possible  be  supported  for  four 
weeks  by  means  of  bandages  (such  as  the  Velpeau)  and  pads,  or  by  a 
spring  truss  or  other  form  of  mechanism.  Pressure  must  be  exerted  in 
the  direction  of  the  articulating  cavity. 

Fractured  clavicle  j)osition  in  bed,  in  addition  to  the  above  means, 
yields  the  best  results.  Backward  displacements  always  prove  the  most 
tractable. 

Dislocations  of  the  Scapula. 

These  displacements  are  usually  called  dislocations  of  the  acromial  end 
of  the  clavicle,  but  in  accordance  with  the  rale  that  the  distal  bone  is  the 
one  dislocated,  they  are  here  termed  dislocations  of  the  scapula.  As  in  the 
case  with  most  luxations  they  may  be  complete  or  incomplete.  When  com- 
plete the  dislocations  of  the  scapula  may  be  sub-,  supra-,  or  post-clavicular. 
Their  general  causes  are  direct  violence  to  the  shoulder  or  muscular  effort. 
When  scapular  dislocations  are  complete  not  only  are  the  ligaments  of  the 
scapulo-clavicular  joint  ruptured,  but  also  often  portions  or  the  whole 
extent  of  the  conoid  and  trapezoid  are  torn. 

Subclavicular  dislocations  are  recognized  by  the  elevated  acromial  end 
of  the  clavicle  and  the  partial  rotation  of  the  inferior  angle  of  the  scapula 
toward  the  spine,  which  latter  symptom  is  due  to  the  dragging  weight  of 
the  arm.  There  is  marked  local  pain,  and  the  attitude  attributed  to  frac- 
ture of  the  outer  end  of  the  clavicle  Is,  in  these  cases,  likewise  assumed. 

Treatment  consists  of  upward,  or  upward  and  outward,  or  backward 


SPECIAL    DISLOCATIONS.  493 

movements  of  the  shoulder,  together  with  direct  pressure  and  moulding. 
In  doing  this  the  arm  should  be  kept  in  contact  with  the  patient's  chest, 
whilst  upward   pressure   is   made  upon  the 
elbow.  Fig.  296. 

Retention  of  the  injured  parts  is  difficult. 
A  Velpeau  or  similar  bandage  or  apparatus, 
or  a  broad  strip  of  adhesive  plaster  carried 
beneath  the  elbow,  up  both  sides  of  the  arm, 
made  to  cross  over  the  acromial  end  of  the 
clavicle  and  secured  upon  the  chest,  back 
and  front,  must  be  worn,  preferably  in  con- 
junction with  the  dorsal  position  in  bed,  for 
a  month. 

Supraclavicular  dislocations  present  the 
acromion  raised  whilst  the  clavicle  can  be 
traced  to  a  certain  point  beneath,  when  it 
disappears  to  palpation.  Reduction  of  this 
variety  is  to  be  accomplished  by  downward  Subclavicular  dislocation  of 
and  backward  traction  upon   the   shoulder,  scapula.    (Bryant.) 

whilst  the  arm  is  kept  parallel  to  the  trunk, 

and  counter-extension  is  exerted  by  traction  upon  a  sheet  wound  around 
the  chest. 

Post-clavicular  dislocation  has  only  twice  been  observed  in  surgical 
history.  It  is  to  be  recognized  by  the  position  of  the  clavicle  directly  in 
front  of  the  acromial  process  of  the  scapula.  A  mingling  of  various 
shoulder  motions  and  manipulation  would  probably  reduce  the  displace- 
ment.    After-treatment  would  be  the  same  as  for  the  previous  varieties. 

Dislocations  of  the  HiimeriLS. 

These  are  the  most  common  of  all  the  dislocations,  a  fact  readily  ex- 
plained by  the  shallowness  of  the  glenoid  cavity,  the  lax  capsular  ligament, 
and  by  the  great  range  of  motion  and  liability  of  the  shoulder  to  direct 
or  transmitted  traumata.  Middle  life  is  the  most  common  time  of  occur- 
rence, and  the  accident  is  rare  at  its  extremes. 

Dislocations  of  the  humerus  group  themselves  into  three  principal 
varieties,  which,  in  order  of  frequency,  are:  1.  Downward  and  some- 
what inward,  or  subglenoid,  often  termed  axillary.  2.  Forward,  which 
embraces  two  sub-varieties,  the  subcoracoid  and  subclavicular.  3.  Back- 
ward or  subspinous.  Other  technical  or  irregular  dislocations  also  have 
taken  place,  but  possess  no  clinical  importance. 

Direct  or,  most  commonly,  indirect  violence  is  the  exciting  cause  of 
dislocation  at  this  joint.  Thus,  waggons  passing  over  the  shoulder  and 
fist  blows  upon  the  arm  have  produced  it,  but  in  vastly  more  instances 
the  head  is  exarticulated  by  force  employing  the  arm  as  a  lever. 

Downward  or  Subglenoid  Dislocations. 

In  downward  dislocation  of  the  humerus  the  capsular  ligament  is  torn 
extensively  upon  its  lower  surface,  the  head  of  the  bone  occupies  a  posi- 
tion upon  the  anterior  surface  of  the  scapula  immediately  beneath  or, 
perhaps,  beneath  and  a  little  to  the  inner  side  of  the  glenoid  cavity,  where 
it  is  held  between  the  tendons  of  the  triceps  and  subscapularis  muscles. 


494     DISEASES    OF    JOINTS,    CARTILAGES     ANM)    LIGAMENTS 


The  axillary  contents  are  compressed  and  the  eircuniHex  nerve  may  be 
so  stretched  or  torn  as  to  result  in  permanent  })araly.sis  of  the  deltoid. 


Fui.  2117. 


Deformity  of  liownwanl  or  subglenoid  dislocation  of  the  humerus.     (Stimson.) 

Whilst  the  bone  is  thus  situated  the  deltoid  and  spinati  muscles  are  made 
exceedingly  tense,  or  may  even  be  partially  ruptured  ;  the  subscapularis 

Fig.  298. 


Downward  dislocation  of  humerus.    (Gross.) 

and   craco-brachialis  muscles  are  likewise   upon   the  stretch,    but  to  a 
less   marked  degree,  and  the  teres  major  and  minor  are  relaxed.     The 


SPECIAL    DISLOCATIONS. 


495 


long  head  of  the  bicej^s  muscle  may  have  been  dragged  out  of  its  groove, 
or  the  great  tuberosity  of  the  humerus  torn  off. 

Subcoracoid  Dislocations. 

When  this  dislocation  has  been  produced,  the  anterior  portion  of  the 
capsular  liagament  is  lacerated.     The  humeral  head  slips  through  this 

rent  and  is  brought  to  a  standstill 
upon  the  inner  surface  of  the  neck 
of  the  scapula  beneath  the  cora- 
coid  process,  or  exceptionally,  as 
far  back  as  the  subscapular  fossa. 
Subcoracoid   dislocations    may   be 

Fir.  300. 


Fig.  2c 


Subcoracoid  dislocation  of  left  shoulder. 
(Stimsox.) 


Subclavicular  dislocation  of  head  oi 
humerus.     (Gross.) 


produced  secondarily  from  the  subglenoid  variety  by  spasmodic  contrac- 
tion of  the  clavicular  portion  of  the  great  pectoral  and  coraco-brachialis 
muscles,  or  during  attempts  at  reduction. 


Subclavicular  Dislocations. 

In  this  form  of  luxation  the  dislocated  bone  extremity  rests  upon  the 
chest  immediately  below  the  clavicle,  and  is  covered  by  the  pectoralis 
major  and  minor  muscles.    (Fig.  300.) 

The  acromial  and  spinous  portions  of  the  deltoid,  the  inner  fibres  of  the 
coraco-brachialis,  and  the  short  and  long  heads  of  the  biceps  muscles  are 
all  very  tense,  whilst  the  teres  major  and  minor  are  correspondingly  re- 


Subspinous  Dislocations. 

This  dislocation  is  one  of  rarity.  The  head  of  the  displaced  bone 
is  to  be  found  posterior  to  the  glenoid  cavity  upon  the  dorsum  of  the 
scapula  immediately  subjacent  to  its  spine. 


•196     DISEASES    OF    JOINTS,    CARTILAGES    AND    LIGAMENTS. 

The  supraspinous  and  subscapular  muscles  are  either  torn  or  ex- 
tremely tense,  as  are  also,  but  in  less  degree,  the  long  head  of  the  biceps 
and  the  clavicular  portion  of  the  deltoid. 


Fig.  301. 


Fig.  302. 


Subspinous  dislocation  of  head  of  hu- 
merus. Front  view.  (Erichskn.) 


Subspinous  dislocation  of  head  of  hu- 
merus. Back  view.  (Erichsen.) 


Fig.  303. 


Subspinous  dislocation  of  head  of  humerus.     (Ekichsen.) 

Symptoms  and  Diagnosis. — For  purposes  of  diagnosis  ether  should 
unhesitatingly  be  administered  if  any  doubt  persist.  In  the  following 
table,  modified  and  adaj^ted  from  Agnew,  are  given  the  symptomatology 
and  differential  diagnosis  of  dislocations  of  the  humerus. 


Doumward  Dislocation.  Forward  Dislocation.  Barhvard  Dislocation. 

(Subglenoid.)  {a.  Subcoracoid  form.)  (Subspinous.) 

1.  Shoulder    cdremely    flat-  1.  Shoulder     flattened,    but  1.  Shoulder  moderately  flat- 

tened, not  extremely  so.  tened. 

2.  Acromion  very  consplcu-  2.  Acromion  prominent.  2  Acromion   moderately 

ous.  prominent. 

3.  Depression    below    entire  3.  Depression  greatest  at  joos-  3.  Depression  greatest  at  a?i- 

arch  of  acromion.  terior   part  of   arch   of  tcrior   part  of    arch   of 

acromion.  acromion. 


SPECIAL    DISLOCATIONS. 


497 


Boionward  Dislocation. 
(Subglenoid.) 

4.  Elbow     projecting     from 

side. 

5.  Axis  of  humerus  directed 

beloiv  glenoid  cavity. 

6.  Inability  to  place  band  of 

injured  side  upon  sound 
shoulder,  or  upon  top  of 
bead. 

7.  Presence  of  bard,  bemi- 

spberieal  tumor  in  axilla. 


Pain    and    numbness    in 
arm  and  fingers. 


Backward  Dislocation, 
(a.  Subcoracoid  form.) 

4.  Elbow     p)™j®cting     from     4 

side. 

5.  Axis  of  humerus  anterior     5 

to  and  below  glenoid  ca- 
vity. 

6.  Inability  to  place  hand  of 

injured  side  upon  sound 
shoulder,  or  u^wa  top  of 
bead. 

7.  Presence  of  hard,  hemi- 

spherical tumor  in  axilla, 
hut  iiighcr  than  in  sub- 


glenoid. 
Pain    and 
arm    and 
marked. 


numbness   in 
fingers    very 


[b.  Subclavicular  form.) 
Differs  from  subcoracoid  as 

follows : 
Acromion  ccceedingly  promi- 
nent. The  round,  hai-d 
tumor  is  immediately  he- 
low  clavicle.  Elbow  di- 
rected backward.  Other- 
wise identical. 


Forward  Dislocation. 

(Subspinous.) 

Elbow  at  side  of  body,  and 
arm  thrown  forward. 

5.  Axis  of  humerus  directed 
behind  glenoid  cavity. 

6.  Ability  to  place  hand  of 
injui-ed  side  upon  sound 
shoulder  and  upon  top 
of  head. 


7.  -ZVb  hard,  round  tumor  in 
accilla,  but  one  present 
helow  spine  of  scapula. 


8.  Great  pain  in  shoulder ; 
little  in  arm  ,•  no  pain  or 
numbness  in  fingers. 


Treatment. — The  ansesthetic  state  to  the  point  of  muscular  relaxation 
should,  as  a  rule,  be  secured  before  attempts  at  replacement  are  undertaken. 
Reduction  is  always  to  be  accomplished  by  manipulation  if  possible,  and 
it  will  be  found  an  exceedingly  unusual  dislocation  of  the  humerus  that 


Fig 


Eeduction  bv  foot  in  axilla.     (Erichsen. 


cannot  thus  be  replaced.  In  using  this  method  the  governing  principles 
which  have  been  already  set  forth  are  to  be  employed  for  the  various 
humeral  dislocations  as  follows :  For  the  subglenoid  variety  the  forearm 
is  flexed  upon  the  arm  to  relax  the  long  head  of  the  biceps.     The  elbow 

32 


498     DISEASES    OF    JOINTS,    CARTILAGES    AND    LIGAMENTS. 


Fig.  305. 


is  then  grasped,  and  tlie  arm  raised  l)v  abduetion  to  the  side  of  the  patient's 
head  to  relax  the  deltoid  and  .supraspinous  muscles.  Now  the  forearm  is 
supinated  to  relax  further  the  long  head  of  the  biceps.  Whilst  the  arm 
is  held  in  this  j)osition  by  one  hand  the  surgeon  places  his  other  upon  the 
prominent  humeral  head  in  the  axilla,  and  as  the  arm  is  drawn  outward 
to  a  right  angle  with  the  body,  lifts  the  head  into  its  socket. 

Subcoracoid  and  subclavicular  dislocations  are  reduced  in  a  similar 
manner,  save  that  after  elevation  the  arm  is  to  he  rotated  outward  before 
being  carried  down,  that  the  spinati  and  teres  minor  muscles  may  be  still 
further  relaxed. 

In  dealing  with  the  subspinous  variety  the  arm  after  being  carried  by 
extreme  abduction  to  the  side  of  the  head  is  rotated  inward  to  relax  the 
subscapularis,  when  the  bone  may  easily  be  replaced  by  direct  pressure 
from  the  fingers  during  adduction.  ]\ranipulation  failing,  the  elbow 
should  be  grasped  and  drawn  forcibly  upward,  while  at  the  same  time 
downward  pressure  is  made  upon  the  shoulder  by  the  other  hand.  Next 
the  surgeon  may  stand  behind  the  patient's  couch,  place  his  foot  upon  the 
shoulder,  and  make  rocking  to-and-fro  traction  and  rotation. 

If  even  after  this  manoeuvre  the  dislocation  persist,  the  surgeon  must 
place  his  unbooted  foot  in  the  axilla  for  counter-extension  and  make 
forcible  traction  upon  the  arm. 

Other  methods  of  reduction  are:  by  right  angle  traction,  using  for 
counter-extension  either  the  bootless  foot  upon  the  chest-wall,  or  a  sheet 
wound  around  from  the  opposite  side ;  by  bending  the  arm  down  over  the 

knee  acting  as  a  fulcrum  in  the  axilla; 
by  placing  an  air-bag  or  other  pad  in 
the  axilla  and  bandaging  the  lower 
arm  as  closely  to  the  side  as  possible, 
which  has  proved  successful,  if  kept  up 
for  days,  even  in  seemingly  hopeless, 
acute,  or  ancient  cases ;  and  lastly  by 
force  in  the  direction  opposite  to  that 
of  dis})lacement.  After  replacement 
the  arm  must  be  kept  in  a  Velpeau 
or  other  similar  bandage  for  a  week, 
and  great  care  must  be  exercised  in  its 
use  for  a  much  longer  period. 

Treatment  of  old  humeral  disloca- 
tions is  always  attended  by  great  danger 
of  serious  accident.  Unless  contra-indi- 
cated by  the  history,  a  luxation  of 
the  humerus  is  scarcely  ever  too  old  to 
try  reduction  upon.  But  if  the  history 
indicates  great  inflammation  and  the 
likelihood  of  arterio-venous  adhesions, 
the  deformity  had  best  be  let  alone  or 
treated  by  other  means  than  reduction. 
If  determined  upon,  reduction  must  be 
attempted  by  separation  of  adhesions  repeated  a  number  of  times 
before  the  final  operation,  when  manipulation  and  force  are  employed. 
This  failing,  if  the  deformity  justitifies  so  severe  a  measure,  the  neck  of 
the  bone  may  be  sawn  through,  and  a  false  joint  established,  or  its  head 
exsected.     Various  accidents  frequently  occur  during  forcible  treatment 


Reduction  by  knee  in  axilla.   (Cooper.) 


SPECIAL    DISLOCATIOiSrS.  499 

of  these  dislocations,  consisting  of  rupture  of  vessels,  nerves,  muscles,  or 
of  the  neck  of  the  bone  itself,  and  abscess.  Wounds  of  the  bloodvessels 
may  be  apparent  at  once  by  the  sudden  formation  of  a  fluid  tumor  in  the 
axilla,  or  may  announce  themselves  later  in  the  shape  of  formation  of  an 
aneurism  or  varix.     If  the  artery  is  torn  the  wrist  pulse  is  absent,  and 

Fig.  306. 


Eeduction  by  upward  traction.     (Cooper.) 

probably  the  rapidly  formed  tumor  in  the  axilla  will  have  pulsation  and 
bruit.  Tumors  appearing  in  the  axilla  at  any  time  after  a  dislocation  of 
the  humerus  should  excite  suspicion  and  always  be  auscultated  before 
any  operation  upon  them  is  undertaken.  Only  general  principles  can  be 
given  for  the  treatment  of  these  accidents.  If  the  artery  be  torn,  ligation 
of  the  subclavian  or  pressure  thereupon  whilst  the  tumor  is  slit  open  and 
the  torn  ends  each  secured,  is  recommended.  Venous  rupture  can  be 
dealt  with  in  the  same  manner,  or,  if  possible,  by  simple  pressure.  Rup- 
ture of  nerves  may  be  repaired  by  their  secondary  suture.  Fractures  and 
ruptures  of  muscles  often  prove  advantageous  from  the  subsequent  relaxa- 
tion and  formation  of  an  artificial  or  false  joint,  but  motion  after  fracture 
must  be  very  guarded  lest  the  vessels  be  torn  by  sharp  edges  or  spicules — 
a  far  from  imaginary  danger. 

Conjoint  Dislocations  of  Radius  and  Ulna. 

Conjoint  dislocations  of  the  radius  and  ulna  take  jDlace  at  the  elbow, 
and  in  either  of  four  directions :  backward,  forward,  inward,  and  outward 
(or  laterally).  The  backward  dislocation  is  much  the  more  common, 
usually  being  produced  by  indirect  violence  acting  through  the  forearm 
when  the  elbow  is  extended.  The  bones  are  thrown  in  various  positions 
under  and  behind  the  condyles  of  the  humerus,  and  further  drawn  up  by 
action  of  the  triceps.  The  capsule  is  torn  and  the  arm  rigidly  flexed  at 
about  a  right  angle,  although  occasionally  some  flexion  and  extension,  or 
even  lateral  motion,  may  be  present.  The  forearm  is  shortened  and  the 
biceps  and  brachialis  anticus  are  very  tense.  Great  pain  is  apt  to  follow 
any  motion. 

Usually  the  diagnosis  is  palpably  evident,  but  in  case  of  doubt  anses- 
thesia  will  quickly  make  it  certain  as  well  as  allow  thorough  rej^lacement. 


500     DISEASES    OF    JOINTS,   CARTILAGES    AND    LIGAMENTS. 


This  is  to  be  accomplished  by  making  traction  upon  the  forearm  and 
backward  pressure  upon  the  lower  end  of  the  humerus  by  a  hand  or  by 


Fig.  307. 


Backward  disloeatinii  of'  radius  ami  ulna.     (Listox.) 

the  knee,  or  the  latter  may  be  employed  as  a  fulcrum  around  which  to 
bend  the  forearm.  When  by  one  of  these  methods  the  bonejis  brought 
into  position  the  forearm  is  flexed  and 

thus  retained  for  two  or  three  weeks  ;  F"'-  309. 

then  passive  motion  is  instituted.  .Stifl^- 
ness  need  not  be  anticipated  in  disloca- 
tions of  the  elbow. 

Tin.  .308. 


Backward  dislocation  of  radius  and  ulna.        Eeduction  of  dislocation  of  radius   and 
(Gross.)  ulna  backward.     (Hamilton.) 


SPECIAJj    DISLOCATIONS, 


501 


.Dislocations  of  the  Radius  and  Ulna  Forward. 

Dislocations  of  the  radius  and  ulna  forward  are  unusual  without  frac- 
ture, being  produced  by  direct  violence.  The  forearm  is  supinated  and 
lengthened,  and  at  a  right  angle  with  the  arm. 

Treatment  consists  of  forced  flexion  and  extension,  and  counter-exten- 
sion, or  flex  and  press  down  upon  the  forearm. 

Lateral  displacements  of  the  radius  and  ulna  are  rarely  complete. 
They  are  unmistakable  and  treated  by  moderate  extension  and  direct 
pressure. 

Divergent  Dislocations  of  the  Radius  and  Ulna. 

Divergent  dislocations  of  the  radius  and  ulna  occur,  but  are  very  rare. 
The  bones  are  both  dislocated  but  do  not  accompany  each  other.  There 
are  two  varieties,  the  antero-posterior  in  which  the  ulna  is  thrown  behind 
the  humerus  and  the  radius  in  front,  and  the  transverse  where  the  ulna  is 
displaced  to  the  inner  side  behind  the  epitrochlea  and  the  radius  to  the 
opposite  side  of  the  humeral  condyles.  They  are  to  be  diagnosed  and 
treated  upon  general  principles. 

Dislocations  of  the  Radius. 

In  luxations  of  this  character  the  head  of  the  radius  is  thrown  from  its 
annular  ligament  and  socket,  either  forward,  outward,  or  backward.  The 
former  direction  is  taken  most  frequently.     The  head  is  absent  from  its 

Fig.  310. 


Backward  dislocation  of  the  head  of  the  radius.  '  (Gross.) 
Fig.  311. 


Forward  dislocation  of  the  head  of  the  radius.     (Gross.) 

normal  position  and  present  in  a  new  locality,  but  the  other  bones  of  the 
elbow  are  in  proper  position. 


502     DISEASES    OF    JOINTS,    CARTILAGES    AND    LIGAMENTS. 

Reduction  is  often  very  difficult,  but  to  be  attained  usually  by  extension 
and  counter-extension  in  the  direction  of  dislocation  plus  direct  moulding 
pressure.  Retention  after  reduction  is  frcrjuently  impossible,  but  fortu- 
nately no  great  deformity  or  loss  of  function  ever  results  if  dislocation 
persists.  An  anterior  angular  splint  and  direct  compress  must  be  kept 
on  for  three  weeks. 


Dislocations  of  the  Upper  End  of  the  Ulna. 

Dislocations  of  the  upper  end  of  the  ulna  take  place  in  a  [backward 
direction  as  a  result  of  indirect  violence.  The  injury  is  a  very  common 
complication  of  high  radial  fracture. 

Fig.  312. 


Dislocation  of  upper  end  of  ulna.     (Cooper.) 

The  radial  head  remains  in  position,  but  the  ulnar  extremity  is  displaced 
beneath  the  condyle  of  the  humerus;  the  forearm  i.s  rigidly  fixed  at  a 
right  angle  and  pronated.  Reduction  is  accomplished  by  placing  the  knee 
in  front  of  the  elbow  and  making  right  angle  traction  upon  the  forearm 
and  direct  pressure  upon  the  displaced  end  of  the  ulna.  This  failing  the 
forearm  should  be  hyperextended  and  traction  made  upon  it,  thus  con- 
verting the  ulna  into  a  lever  of  the  second  class,  which  brings  the  coronoid 
process  over  the  condyles  of  the  humerus. 


Dislocations  of  the  Lower  End  of  the  Ulna. 

Dislocations  of  the  lower  end  of  the  ulna,  from  its  articulation  with 
the  radius,  take  place  in  either  forward,  backward,  or  inward  direction ; 
the  forward  variety  being  induced  by  violent  supination  of  the  forearm, 
and  the  backward  form  by  forcible  pronation.  Reduction  is  easily  accom- 
plished by  fixing  the  radius  and  then  restoring  the  ulna  to  proper  position 
by  direct  pressure.  Antero-posterior  splints  should  be  kept  on  from  three 
to  four  weeks. 

Dislocations  of  the  Carpus. 

This  dislocation  almost  never  exists  without  fracture.  The  direction  of 
displacement  is  either  forward  or  backward,  and  is  to  be  diagnosed  by  the 
abrupt  angle  formed  by  the  displaced  carpus  and  the  extremities  of  the 


SPECIAL    DISLOCATIONS. 


503 


radius  and  ulna,  and  by  the  relation  of  the  former  to  the  processes  of  the 
latter,  more  especially  to  the  styloid  process  of  the  radius.  Restoration  is 
effected  by  extension  and  backward  and  forward  motion  of  the  hand. 


Backward  dislocation  of  carpus.     (Fergusson.) 

Dislocations  of  individual  bones  of  the  carpus  occur  in  an  upward 
direction  and  have  been  twisted  out  of  place.     Manipulation  and  direct 

Fig.  314. 


Forward  dislocation  of  cariaus.     (Feegusson.) 

pressure  will  usually  reduce  them,  but  failing  in  this  they  should  be  ex- 
cised through  a  sufficient  incision.  A  pad,  palmar  splint,  and  bandage 
must  be  applied  and  worn  for  about  a  week. 

Dislocations  of  the  Metacarpal  Bones. 

Dislocations  of  the  metacarpal  bones  are  not  uncommon,  in  direction 
observe  either  an  upward  or  backward  direction,  and  are  easily  reducible 
by  the  usual  method  of  extension  and  pressure. 

Dislocations  of  the  Phalanges  of  the  Sand. 

Dislocations  of  the  phalanges  of  the  hand  are  of  common  occurrence, 
usually  taking  place  at  the  metacarpo-phalangeal  junction.     They  are,  as 


504    DISEASES    OF    JOIXTS,    CARTILAGES    AND    LIGAMENTS. 

a   rule,  difficult  neither  of  recognition  nor  treatment  ;  simple  traction  hy 
the  hand  of  the  surgeon,  perhaps  assisted  by  a  clove  hitch  about  the  in- 


Fic.  Sla. 


Extension  by  Indian  jmzzle.     (Bryant 


jured  finger,  or  by  the  Levis  or  "  Indian  puzzle"  apparatus,  usually  suf- 
ficing for  restoration. 

Fk;.  Sir,. 


Levis's  extension  apixiratus. 

But  at  time*  one  of  the  displaced  bones  becomes  entangled,  and  then 
skilful  manipulation,  or  even  division  of  the  constricting  band,  will  be- 
come   necessary.     Especially   is   this 
Fk-  317.  true  of  backward  dislocations  of  the 

proximal  phalanx  of  the  thumb.  In 
this  luxation  the  head  of  the  meta- 
carpal bone  may  slip  through  the  in- 

FiG.  .-^18. 


Backward  dislocation  of  proximal  phalanx 
of  thumb,  showing  metacarpal   head  thrust 
Dislocation  of  proximal  phalanx  of    through  and  held  by  heads  of  short  flexor 
tliumb  backward.     (Ashhurst.)        muscle.     (Agxew.) 


SPECIAL    DISLOCATIONS. 


505 


terval  between  the  two  heads  of  the  short  flexor  muscle,  when  forcible 
reduction  becomes  impossible. 

Eeduction  must  then  be  accomplished  by  manipulation  as  follows: 
extend  the  thumb  upon  the  wrist  until  its  tip  points  to  the  elbow,  when 
the  end  of  the  phalanx  will  press  upon  and  separate  the  then  relaxed 
heads  of  the  short  flexors ;  then  place  a  finger  behind  the  phalanx  to  pre- 
vent its  head  slipping  upward,  and  bring  the  thumb  down  to  its  proper 
position.  This  manoeuvre  failing,  the  restricting  tendon  must  be  divided  by 
subcutaneous  or  open  incision.  The  parts,  in  any  case,  must  be  kept  at 
rest  by  a  spica  of  the  thumb  or  splint  for  three  weeks.  Old  dislocations 
of  this  joint  may  demand,  should  all  of  the  above  measures  fail  and  dis- 
ability justify,  the  excision  of  the  metacarpal  head,  or  even  amputation 
of  the  member  through  the  metacarpo-phalaugeal  joint. 


Dislocations  of  the  Fewur. 

Luxations  of  the  femur  take  place  at  the  hip-joint,  and  comprise  about 
nine  per  cent,  of  all  dislocations.  The  head  of  the  femur,  after  leaving 
the  acetabulum,  may  occupy  any  position  about  the  joint,  depending  upon 
the  direction  of  the  applied  force,  the  position  of  the  limb  at  time  of 
accident,  and  the  extent  of  liga- 
mentous and  muscular  lacera-  Fig.  319. 
tion.  As  a  rule,  regular  dislo- 
cations may  be  said  to  occur 
when  one  or  both  branches  of 
the  ileo-femoral  ligament  remain 
intact,  and  the  irregular  or 
anomalous  when  that  ligament 
is  extensively  or  completely 
lacerated.  The  rdle  of  this  liga- 
ment in  the  production  and 
treatment  of  hip  dislocations  is 
of  extreme  importance.  It  origi- 
nates upon  the  front  and  outside 
of  the  anterior  inferior  spinous 
process  of  the  ilium,  crosses 
downward,  spreading  over  the 
anterior  surface  of  the  hip- 
joint,  and  divides  into  two  por- 
tions ;  the  outer  to  be  inserted 
into  the  trochanter  major,  and 
the  inner  into  the  trochanter 
minor.  This  ligament  being  ex- 
tremely powerful,  usually  pre- 
vents the  head  of  the  femur 
quitting  the  acetabulum  save  in 
a  posterior  or  lateral  direction. 

Femoral  dislocations  are  al- 
ways caused  by  indirect  violence, 
and  may  be  classed  in  two  great 
divisions :  those  where  the  head 
is  thrown  anteriorly  to  the  gle- 
noid cavity,  or  forward  dislocations,  and  those  where  it  is  displaced  pos- 
teriorly, or  backward  dislocations.     Of  each  of  these  classes  there  are 


Ileo-fernoral  ligament.     (BiGELOTr. 


r)06    DISEASES    OF    JOINTS,   CARTILAGES    AND    LIGAMENTS. 

two  principal  varieties,  whicli  will  be  described,  also  a  ,<,'reat  number  of 
unpractical  subdivisions  which  will  not  be  separately  considered.  Back- 
ward dislocations  comprise  more  than  three-fourths  of  hip  displacements. 
They  are  divided  into  those  directly  backward  into  the  sciatic  foramen 
(ischiatic),  and  those  backward  and  upward  u|)on  the  dorsum  of  the  ilium 
(iliac).  The  upward  variety  is  most  common  of  all  hi])  dislocations, 
whilst  the  directly  backward  dislocation  ranks  second. 

Of  forward  dislocations  we  have  the  forward  and  downward  into  the 
thyroid  foramen,  and  the  forward  and  upward  upon  the  pubis,  or  pubic 
dislocation  ;  the  latter  being  rare,  but  the  former  ranking  third  of  all  hip 
displacements.  The  capsular  and  round  ligaments  are  invariably  torn, 
and  the  femoral  vessels  may  be  injured  in  forward,  and  the  sciatic  nerve 
in  backward  dislocations. 

Femoral  dislocations  are  invariably  to  be  first  treated  by  manipulation 
under  profound  anresthesia,  but  should  this  method  fail,  then  extension 
and  counter-extension  in  the  line  of  dislocation  may  be  judiciously  em- 
ployed ;  but  should  both  measures  prove  inefficient  after  several  trials,  at 
intervals,  incision  and  division  of  the  restricting  tissues,  section  of  the 
neck,  or  even  excision  of  the  head,  should  receive  consideration. 


Posterior  or  Backward  Didoeations. 

When  these  dislocations  occur  the  capsule  is  ruptured  posteriorly  upon 
its  outer  aspect,  and  the  head  of  the  bone  is  shot  in  a  backward  or  upward 
antl  backward  direction. 

Backward  and  Upward  (Iliac  or  Dorsal)  dis- 
placements take  place  when  the  limb  is  abducted 
and  forcibly  rotated  inward,  or  by  a  force  applied 
from  below  when  the  legs  are  crossed.  Simple 
inward  rotation,  however,  may  prove  sufficient  for 
its  production. 

Symptoms. — The  thigh  is  somewhat  flexed  and 
adducted,  the  knee  of  the  injured  thigh  is  slightly 
above  and  in  front  of  its  fellow,  and  is  in  contact 
with  the  lower  and  inner  portion  of  the  oppo- 
site thigh.  The  foot  is  forcibly  inverted  and  the 
ball  of  the  great  toe  touches  the  inner  portion  of 
the  opposite  instep.  The  injured  hip  is  exceed- 
ingly prominent,  whilst  the  head  of  the  femur  can 
usually  be  felt  upon  the  dorsum  of  the  ilium. 
There  is  shortening  of  the  injured  limb  to  the  ex- 
tent of  from  one  to  two  and  a  half  or  three  inches, 
according  to  the  height  of  the  head  upon  the  ilium  ; 
flexion  and  extension  are  moderately  interfered 
with,  but  the  motions  of  adduction  and  abduction 
are  almost  impossible.  Xumbuess  or  tingling  of  the 
sciatic  distribution  may  or  may  not  be  present,  but 
in  any  case  always  is  moderate. 

Backward  (Ischiatic)  dislocations  occur  wdiilst 
the  thigh  is  at  right  angles  with  the  pelvis  and  is 
abducted  and  rotated  inward ;  the  head  of  the  femur 
is  displaced  directly  backward  and  comes  to  a  stand- 
still in  the  sciatic  foramen.  Portions  of  the  glutei,  gemelli,  and  obturator 
externus  muscles  are  usually  lacerated  by  the  head  in  transit. 


Backward  and  upward 
(or  iliac)  dislocation  of 
the  femur.     (Cooper.) 


SPECIAL    DISLOCATIOXS. 


507 


Symptoms. — The  thigh  is  slightly  flexed,  inverted,  and  addueted;  the 
knee  touches  the  opposite  limb  at  the  inner  and  upper  margin  of  the 
patella. 

The  extremity  of  the  great  toe  of  the  injured  side  just  touches  the 
nietatarso-phalangeal  articulation  of  its  fellow.  Shortening  never  exceeds 
half  an  inch,  and  may  even  be  lacking. 

Its  presence  is  best  demonstrated,  as  Fig.  322. 

suggested  by  O.  H.  Allis,  if  the  thighs 
be  flexed  to  a  right  angle  with  the 
pelvis  and  the  condyles  of  the  femurs 
compared. 

The  hip  is  somewhat  prominent. 
Numbness,  tingling,  or  palsy  of  the  sci- 
atic distribution  may  be  very  marked. 
The  head  of  the  femur  is  lower  and 
less   prominent   than   in   the    upward 

Fig.  321. 


AUis's  test  for  shortening  in  backward 
dislocation  of  femiar. 


Backward  (ischiatic)  dislocation  of 
the  femur.     (Cooper.) 


and  backward  displacement,  and  the  psoas  and  iliac  muscles  being  tense 
the  trunk  is  thrown  slightly  forward.  Eectal  or  vaginal  examination 
may  clear  up  a  doubtful  diagnosis  by  demonstrating  the  head  in  the 
sciatic  foramen. 


Treatment  of  Posterior  Dislocations  (^Iliae  and  Ischiatic). 

Reduction  can  almost  always  be  accomplished  by  manipulation.  The 
patient  should  be  etherized  to  relaxation  and  placed  flat  upon  his  back. 
The  surgeon  then  grasps  the  leg  at  the  foot  and  knee,  flexes  the  leg  upon 
the  thigh  and  the  thigh  upon  the  abdomen ;  then  adducts  the  limb  and 
rotates  it  outward,  carries  it  to  the  sound  side,  sweeps  it  outward  across 
the  abdomen,  and  brings  it  out  straight,  when  the  head  will  return  to  the 
socket,  perhaps  with  a  very  audible  snap. 

It  will  be  observed  that  during  these  manipulations  the  ileo-femoral 
ligament  is  relaxed  by  flexing  the  thighs,  which  also  in  the  simple  back- 
ward dislocation  frees  the  head  from  possible  entanglement  with  the 
tendon  of  the   obturator  internus;   that  external  rotation  and  eircum- 


508     DISEASES    OF    JOINTS,    CARTILAGES    AND    LIGAMENTS. 

duction  winds  the  outer  branch  of  the  ileo-feiiioral  ligament  around  the 
neck  of  the  fermur  and  thus  carries  the  head  over  the  acetabuhir  rim  and 
into  normal  position.     Extension  and  counter-extension  in  the  line  of  dis- 


FiG.  323 


Fig.  324. 


Reduction  of  backward  (iliac 
and  sciatic)  dislocation  of  the 
femur.     (Bioelow.) 


Mechanism  of  reduction  of  backward  disloca- 
tions of  tlie  femur.     (AiiXKW.) 


location  may  be  judiciously  employed  should  manipulation  fail,  but  if 
both  prove  inefficient  after  several  trials  at  intervals,  open  arthrotomy,  or 
section  of  the  neck  or  even  excision  of  the  head  should  receive  con- 
sideration. 

Anterior  or  Fortmrd  Dislocations. 

Forward  and  downward  (thyroid  or  obturator)  dislocations  result  from 
the  application  of  force  when  the  limb  is  abducted  ;  the  inner  and  posterior 
portions  of  the  capsular  ligament  are  torn  and  the  head  of  the  femur  is 
thrust  into  the  thyroid  foramen  and  rests  upon  the  obturator  externus 
muscle. 

Symptoms. — The  limb  is  lengthened  from  one  to  one  and  a  half 
inches,  abducted,  and  the  heel  is  somewhat  raised  when  the  patient  stands, 
The  toes  point  forward  and  may  be  everted ;  the  hip  is  flattened  and 
the  trunk  is  inclined  forward  and  to  the  injured  side.  The  femoral  head 
can  be  distinctly  felt  below  the  horizontal  ramus  of  the  pubis.  These 
symptoms  are  to  be  interpreted  as  follows:  abduction  is  due  to  tension  of 
the  glutei  muscles  and  to  the  tenseness  of  the  inner  branch  of  the  ileo- 
feraoral  ligament ;  the  body  is  inclined  to  relax  the  stretched  psoas 
maguus  and  iliacus  muscles. 

Treatment  must  be  conducted  whilst  the  patient  is  fully  relaxed  by 
aniesthesia.  Reduction  is  accomplished  by  manipulation,  exactly  as  for 
backward  dislocations,  save  that  inward  rotation  and  circumduction  are 
here  employed. 

Thus  the  psoas  muscle  and  ileo-femoral  ligament  are  relaxed  by  flexion, 
and  the  internal  branch  of  that  ligament  is  wound  about  the  neck  of  the 
femur  in  inward  rotation  and  circumduction,  and  draws  the  bone  over 
the  acetabular  rim  into  position. 

Anterior  luxations  may  be  converted  into  posterior  varieties  during 
manipulation,  when  obviously  rotation  and  circumduction  must  be  made 
as  for  reduction  of  the  latter  class. 


SPECIAL    DISLOCATIONS. 


509 


Forivard  and  upward  dislocations  (pubic)  are  quite  rare  and  most  in- 
frequent of  all  femoral   displacements.     Hyper-extension  of  tlie  thigh, 


Fig.  325. 


Fig.  326. 


Forward  and  downward  dislo- 
cation (thyroid  or  obturator)  of 
the  femur.     (Cooper.) 

Fig.  327. 


Forward  and  downward  dislocation  of  the  femur. 

(BiGELOW.) 

Fig.  328. 


deduction  of  forward  dislocations  Mechanism  of  reduction  of  forward  dis- 

(iliac,   thyroid    and   pubic)    of    the  locations  of  the  femur.     (Bigelow.) 

femur.     (Bigelow.) 

plus  an  inward  rotary  motion  or  a  blow  upon  the  foot  are  the  most  usual 
means  of  production  of  these  unusual  injuries.     The  anterior  inner  por- 


510     DISEASES    OF    JOINTS,    CARTILAGES    AND    LIGAMENTS. 


/ 


tiou  of  the  capsular  lii^ament  is  lacerated  and   the  head  of  the  fetmir 
rests  usually  upon  the  pubis  in  front  of  the  horizontal  ramus,  although 

exceptionally  it  may  not  be  arrested  before 
I'^'G   :^2',t.  it  has  even  passed  above  the  pubis. 

Symptoms. — The  linil)  is  shortened  and  ab- 
ducted, the  foot  much  everted,  the  thigh  some- 
what flexed,  the  heel  is  raised  a  little  from  the 

Fir..  3.30. 


Forward  and  upward   (i)uhic)  dis- 
location of  the  femur.    (Cooper.) 


Forward  and  ujiward  (pubic)  dislocation 
of  the  femur.     (Agxew.) 


ground,  and  the  bony  head  can  l)e  felt  in  front  of,  or  above  the  pubis. 
Abduction  and  eversion  are  due  to  tension  of  the  anterior  branch  of  the 
ileo-femoral  ligament  and  external  rotatoi's  of  the  hip.  Reduction  is 
attained  by  the  same  manipulation  as  for  forward  and  downward  displace- 
ment, but  flexion  and  abduction,  pi-evious  to  internal  rotation,  should  be 
more  decided. 

Old  Dislocations  of  the  Femur. 

Femoral  luxations  are  termed  old  when  they  have  remained  unreduced 
upward  of  six  or  eight  weeks;  reduction  has  been  accomplished  many 
times  when  the  injury  had  persisted  to  periods  as  long  as  five  years. 
Prudent  attempts  should  be  made  in  any  case,  regardless  of  duration,  by 
appropriate  manipulation  and  extension  and  counter-extension ;  never, 
however,  employing  great  force  or  persistence.  If  there  is  a  history  of 
inflammation,  or  if  great  changes  have  occurred  in  the  acetabulum  or 
femoral  head,  manipulative  efforts  should  not  be  attempted.  In  any  case 
if  deformity  and  disability  are  great  section  of  the  femoral  neck  or  excision 
of  the  head  may  become  permissible.  Subtrochanteric  section  of  the  femur 
may,  in  other  cases,  be  employed  with  good  results,  and  should  fracture 
occur  at  or  near  this  point  during  reduction  endeavors  it  will  be  fortunate 
as  then  passive  motion  can  be  kept  up  and  a  useful  false  joint  thereby 


SPECIAL    DISLOCATIONS. 


511 


secured.  Paralysis  of  the  nerves,  or  pressure  upon  bloodvessels  may- 
demand  operation.  The  sciatic  nerves  may  be  torn  during  reduction  ; 
abscesses  may  follow  any  interference. 


Fia.  33L 


INNER  CONDYLE 
I  OF  FEMUR 
/-HEAD  OF  TIBIA 


Dislocations  of  the  Tibia. 

Dislocations  of  the  tibia  occur  at  the  knee-joint  and  include  1  per  cent, 
of  all  dislocations.  According  to  frequency,  dislocations  occur  forward, 
backward,  outward,  and  inward.  Rotary 
dislocation  also,  but  rarely,  is  produced 
by  twisting  force.  Any  of  the  prin- 
cipal varieties  may  be  complete  or  par- 
tial. These  injuries,  especially  if  com- 
plete, are  always  serious,  and  are 
accompanied  by  such  extensive  lacera- 
tion of  ligaments  and  surrounding  tis- 
sues and  vessels  as  to  demand  excision 
or  amputation.  The  popliteal  vessels 
and  nerves  are  especially  liable  to 
stretching  or  rupture  ;  a  clot  may  sub- 
sequently be  formed  in  the  artery.  The 
direction  of  displacement  can  be  recog- 
nized with  facility  by  the  bony  land-  "^^ 
marks  of  the  joint,  but  occasionally, 
when  complications  or  great  swelling- 
have  occurred,  anaesthesia  may  be  neces- 
sary to  confirm  or  make  the  diagnosis. 
Shortening  will  be  present  if  there  is 
overlapping ;  the  part  may  be  either 
rigid  or  flaccid.  The  direction  of  the 
foot  will  indicate  rotary  dislocation 
and  its  direction,  should  the  displace- 
ment have  assumed  that  type ;  the 
crucial  ligaments  are  almost  invariably 
torn. 

Reduction  of  tibial  dislocations  is 
made  by  traction,  extension  ;  and  oppo- 
site rotation  for  the  rotary  variety. 
Subsequent  rest  upon  a  posterior  splint 
for  several  weeks  is  essential.  Then 
massage  and  passive  motion.  Anky- 
losis of  varying  degree  is  apt  to  sue-  Roberts's  case  of  unreduced  dislocation 
ceed.  of  patella. 


Dislocations  of  the  Patella. 

Dislocations  of  the  patella  occur  with  outward  or  inward  displacement 
of  that  bone  or  it  may  be  partially  or  completely  rotated  upon  its  axis, 
or  the  latter  may  occur  in  conjunction  with  the  former.  Outward  dis- 
location, because  of  the  axes  of  insertion  of  the  patellar  ligaments,  is 
most  common  ;  all  are  caused  by  muscular  contraction  or  direct  violence. 
Complete  rotation  has  twice  been  reported,  and  cases  of  habitual  luxation 
are  upon  record. 


512    DISEASES    OF    JOINTS,    CARTILAGES    AXD    LIGAMENTS. 

Reduction  is  effected  by  rapidly  succeeding  partial  flexions  and  com- 
plete extensions  of  the  leg,  plus  manipulation  of  the  bone  itself  and 
pressure  in  the  direction  opposite  to  that  of  dislocation.  This  failing, 
especially  in  complete  rotations,  incision  and  forcible  replacement  be- 
come necessary. 

Dislocations  of  the  Fibula. 

Dislocations  of  the  fibula  take  place  at  either  of  its  extremities.  The 
bone  is  forced  from  its  tibial  articulations,  and  forward,  upward,  or  back- 
ward displacements  are  possible.  To  reduce  them  the  knee  is  partially 
flexed  and  direct  pressure  is  applied,  and  succeeded  by  splint  or  bandage. 

Dislocations  at  the  Ankle-joint. 

Under  this  head  are  included  only  dislocations  of  the  foot  as  a  whole 
from  the  tibia  and  fibula.  These  occur  backward,  forward,  and  laterally, 
are  most  frequently  associated  with  fracture,  and  as  often  difficult  to  dif- 
ferentiate therefrom.  Lateral  dislocation  is  almost  always  associated  with 
fracture  of  a  malleolus.  They  are  to  be  reduced  by  flexion  of  the  leg, 
direct  pressure,  and  manipulation  of  the  foot.  Should  contraction  of  the 
calf  muscles  constantly  reproduce  the  dislocation  and  not  be  contnjllable 
by  a  temporary  tight  bandage,  the  tendo-Achillis  must  be  divided. 

Dislocations  of  the  Various  Bones  of  the  Tarsus. 

Dislocations  of  the  various  bones  of  the  tarsus  are  not  infrequent  inju- 
ries, easily  diagnosed,  and  are  treated  by  direct  pressure,  manipulation, 
or  should  these  methods  fail,  by  excision  of  the  displaced  bone. 

The  astragalus  may  be  dislocated  backward,  forward,  and  outward,  or 
forward  and  inward,  In  the  former  variety  the  extremity  is  shortened, 
the  astragulus  may  be  felt  in  front  of  one  of  the  malleoli,  whilst  the  foot 
is  extended  and  twisted  to  the  opposite  side.  When  displacement  is  back- 
Avard  the  foot  is  extremely  flexed,  the  instep  is  short,  and  the  heel  elon- 
gated. The  astragalus  is  to  be  felt  beneath  the  distorted  and  tense 
tendo-Achillis. 

Reduction  of  the  forward  and  lateral  varieties  can  usually  be  performed 
by  flexion  of  the  leg,  traction  upon  the  foot,  and  direct  pressure  upon  the 
astragalus.  Division  of  the  tendo-Achillis  may  assist  in  replacement. 
Backward  dislocations  usually  prove  irreducible,  and  the  bone  should  be 
excised  at  once  or  at  a  later  time. 

Metatarsal  dislocations  and  those  of  the  phalanges  of  the  toes  are  rare 
injuries,  usually  due  to  crushing  force  necessitating  amputation ;  other- 
wise they  are  to  be  treated  upon  general  principles  of  reduction. 


Dislocation  of  Cartilages. 

Dislocation  of  the  Costal  Cartilages. 

Dislocations  of  the  costal  cartilages  from  their  various  junctions  with 
the  sternum,  the  ribs,  and  from  their  points  of  mutual  contact,  are  possi- 
ble, but  of  very  infrequent  occurrence.  Direct  or  indirect  force  is  always 
the  causative  factor. 


SPECIAL    DISLOCATIONS.  513 

Symptoms  are  undue  prominence  or  depression  at  the  seat  of  articula- 
tion, undue  mobility,  perhaps  modified  crepitus,  pain,  or  disturbed  respi- 
ration. These  displacements  are  to  be  treated  by  moulding,  manipulation 
of  shoulders,  forced  expiration  or  inspiration,  and  after  reduction  are  to 
be  kept  in  place  by  means  of  suitable  pads  or  bandages. 

Dislocation  of  the  Ensiform  Cartilage. 

Dislocation  of  the  ensiform  cartilage  has  only  twice  been  reported ;  in 
both  instances  backward  and  by  direct  force.  Symptoms  were  intense 
gastric  pain  and  vomiting,  embarrassed  respiration,  absence  of  ensiform 
upon  palpation.  Reduce  by  same  methods  as  for  dislocated  costal  carti- 
lages. If  distress  is  great,  and  these  methods  fail,  a  hook  may  be  inserted 
through  the  integument  and  beneath  the  tip  of  the  ensiform,  when  it  may 
be  drawn  back  into  position.  Or  a  finger  may,  through  an  incision,  be 
likewise  hooked  under  the  cartilage.  If  it  cannot  be  so  reduced,  or  if  dis- 
location is  constantly  repeated,  then  nothing  will  remain  but  to  excise  the 
offending  cartilage  through  a  vertical  incision  of  its  own  length  directly 
over  it.  The  cartilage  is  then  seized  with  lion  forceps,  its  surrounding 
attachments  carefully  divided,  it  is  withdrawn,  and  the  wound  sutured 
with  or  without  a  small  drain. 

As  life  advances  dislocations  of  chest  cartilages  give  place  to  fractures, 
because  of  the  ossific  deposits  in  these  cartilages  in  the  aged.  Treatment 
would  be  the  same  as  that  for  fracture  of  the  respective  proximal  bones. 

Dislocation  of  the  Semi-lunar  Cartilages. 

Dislocation  of  the  semi-lunar  cartilages  is  not  an  uncommon  injury  ; 
is  directly  produced  by  excessive  flexion  or  a  sudden  wrench,  and  is 
almost  limited  to  persons  of  middle  age,  especially  those  who  have  lax 
or  previously  diseased  joints.  The  displacement  is  generally  backward, 
but  may  be  in  the  opposite  direction.  Both  cartilages  may  participate  ia 
the  dislocation,  but  more  usually  the  inner  one  alone  is  affected.  Both 
knees  may  be  attacked  at  the  same  or  different  times.  The  etiological 
factors  are  a  relaxed  or  previously  lacerated  knee-joint  or  crucial  liga- 
ments, and  excessive  flexion ;  by  which  the  cartilages  are  forced  out  of 
place,  perhaps  crumpled  upon  themselves,  and  become  wedged  at  some 
point  between  the  femoral  condyles  and  the  tibia,  stretching  or  tearing 
the  crucial  ligament,  if  they  have  not  previously  been  the  seat  of  rupture, 
and  appreciably  separating  the  articular  surfaces  of  the  bones  entering 
the  joint. 

Symptoms. — During  stooping,  squatting,  kneeling,  or  other  excessive 
flexion  of  the  knee  a  sudden,  intense,  sickening  pain  is  experienced  in 
one  or  both  knee-joints.  The  joint  has  become  locked  in  a  position  of 
extreme  flexion  and  cannot  be  extended  by  the  patient  or  by  application 
of  force.  If  predisposition  exists  the  accident  may  happen  to  a  joint 
when  it  is  but  partly  flexed,  and  when  dislocation  occurs  perhaps  throw 
the  person  violently  down.  Compai'ed  with  the  corresponding  joint  the 
bones  entering  it  are  notably  separated,  and  perhaps  the  displaced  carti- 
lage can  be  felt  in  the  interval.  If  the  luxation  is  not  soon  reduced 
efflision  will  take  place,  inflammation  arise,  and,  possibly,  abscess  later 
occur.  Even  when  early  replaced,  efflision  and  a  sharp  synovitis  may 
follow. 

33 


514     DISEASES    OF    JOINTS,   CARTILAGES    A  N"  l»    LIGAMENTS. 


Fig.  S.'?2. 


Treatmknt. — The  displiU'einent  can  almost  always  l)e  reduced  in.stantiy 
bv  liyperriexion  of  the  knee  over  the  edge  of  a  tai)le  or  around  a  hed- 
po^^t.  followed,  while  extension  is  made  by  a  hand  behind  the  calf,  by  sud- 
den full  extension.     For  this  anaesthesia  is  advisable,  as  the  accompanying 

])aiu  is  great.  Following  reduction  of  such 
cases  the  joint  should  be  immobilized  for 
three  weeks  by  a  plaster  dressing  or  splint 
that  inflanunation  may  be  averted  and  the 
rujitured  ligaments  be  given  a  chance  to 
unite.  If  reduction  cannot  be  thus  accom- 
plished after  a  number  of  eflbrts,  and  in 
cases  where  constant  recurrence  (which 
cannot  be  prevented  by  wearing  a  tense 
rubber  knee-cap  or  apparatus  which  will 
prevent  more  than  a  slight  degree  of  flex- 
ion) renders  a  patient  unfit  for  occupa- 
tion or  enjoyment  of  life,  the  following 
operation,  devised  by  Annandale,  should 
be  forthwith  performed.  Starting,  ac- 
cording to  whether  the  internal  or  ex- 
ternal cartilage  is  affected,  upon  the 
inner  or  outer  border  of  the  insertion 
of  the  ligamentum  patella,  an  incision  is 
carried  upward  and  inward  to  an  extent  of  three  inches,  and  downward 
until  svnovial  membrane  is  reached. 


Clamp  to  prevent  dislocations  of  the 
semi-lunar  cartilage.     (Marsh.) 


Fig.  332 


Apparatus  for  cases  subject  to  dislocation  of  semi-lunar  cartilage.    (Marsh.) 


All  bleeding  being  arrested,  the  membrane  is  opened  as  freely  as  pos- 
sible in  the  line  of  incision,  the  offending  cartilage  caught  and  pulled  to 
the  surface  with  a  blunt  hook  or  forceps,  and  there  sutured  by  at  least 
three  sutures  of  strong  catgut  to  the  fascia?  and  periosteum  covering  the 
tibial  head.  The  synovial  and  superficial  wounds  are  then  separately 
sutured  and,  the  limb  being  extended,  a  plaster  dressing  or  suitable  splint 
is  applied  and  not  removed  for  several  weeks,  when  gentle  passive  move- 
ments may  be  made,  and  at  the  end  of  two  months  the  patient  may  be 


EXCISION    OF    JOIXTS. 


515 


allowed  to  walk.      This    operation   failing   to   give    relief,   the    affected 
cartilage  may,  through  a  similar  incision,  be  bodily  excised. 


Operations  upon  Joints. 

Aspiration  of  joints  is  performed  by  introducing  an  aspirator  needle 
through  the  perfectly  cleansed  integuments,  usually  at  the  most  promi- 
nently distended  point,  into  the  joint  cavity,  and  thereby  withdrawing  the 
fluid  contents. 

Washing  out  or  irrigation  of  joints  may  be  performed  either  by  pump- 
ing the  irrigating  solution  through  the  aspii'ator  needle,  and  then  sucking 
it  out  again,  by  introducing  two  canulee  upon  the  same  or  opposite  sides 
of  the  articulation  and  pumping  in  through  one  and  out  through  the 
other,  or  by  making  a  short  incision  in  the  axis  of  the  joint  and  through 
it  pumping  the  fluid. 


Aspiration  aiDiDaratus. 

Exploration  of  joints  is  accomplished  through  incisions  exactly  similar 
to  those  for  excision  of  the  corresponding  joint,  whereby  the  articulation 
is  laid  open  to  touch  and  sight. 

Erasion  of  a  joint  indicates  laying  it  open  as  for  excision,  and,  if  the 
disease  is  found  to  involve  simply  synovial  membrane,  ligaments,  or  super- 
ficial cartilages,  removal  of  the  affected  parts  by  knife,  scissors,  or  curette 
without  interference  with  bone,  afterward  washing  the  cavity  out  and 
treating  it  as  if  excised.  If  thoroughly  performed  and  early  enough 
undertaken  this  operation  yields  excellent  results. 


Excision  of  Joints. 

By  excision  of  a  joint  is  meant  the  total  or  partial  removal  of  the 
articular  surfaces  and  other  structures  comprising  the  articulation,  or  the 
removal  of  a  portion  of  bone  where  ankylosis  has  taken  place.  Its 
object  is  to  secure  total  eradication  of  the  disease  with,  in  some  instances, 
subsequent  bony  ankylosis,  in  others  pseudo-arthrosis,  or  fibrous  union. 

Contra-indications  are :  very  extensive  bone  or  surrounding  tissue  in- 


51(3     DISEASES    OF    JOINTS,    CARTILAGES    AND    LIGAMENTS, 


volveinent,  osteomyelitis,  advanced  age,  organic  complications  such  as 
phthi.<is,  amyloid  disease,  diabetes  or  nephritis,  great  exhaustion.  Ex- 
cision should  never  be  performed  for  malignant  disease  of  joints  or 
neighboring  bones. 

Excision  may  be  indicated  for : 

(a)  disease, 

(6)  ankylosis, 

(c)  injury. 

(a)  Disease  most  often  demands  excision.  Chronic  synovitis  and  the 
varied  forms  of  arthritis  furnish  a  large  majority  of  operations.  Bone 
abscess  opening  into  a  joint,  and  chronic  gonorrhteal  or  rheumatic 
arthritis  occasionally  demand  it. 

(b)  Ankylosis  of  certain  joints,  such  as  the  elbow,  knee,  or  jaw  in 
awkward  positions,  may  justify  excision. 

Bad  positions  of  the  hip  and  shoulder  always,  and  those  of  the  knee 
and  jaw  sometimes,  can  be  better  corrected  by  osteotomy  of  proximal 
bones  than  by  excision.  AVhen  the  elbow,  shoulder,  or  maxillary  articu- 
lations are  excised,  fibrous  union  and  false  joint  should  be  striven  for. 

(c)  Excision  is  unsuited  for  violent  crushing,  or  very  extensive  gunshot 
wounds  of  joints,  or  in  those  where  the  popliteal  vessels  are  involved. 
But  in  certain  common  shot  wounds,  fractures  into  joints,  and  disloca- 
tions, it  is  eminently  appropriate.  In  these,  if  bony  ankylosis  is  not  de- 
sired, often  a  partial  excision,  as  of  one  articulating  surface,  will  suffice. 
Excision  may  also  be  indicated  for  old  unreduced  or  constantly  recurring 
dislocations,  as  well  as  for  acute  joint  disease  following  injury  or  opera- 
tion. 


Fig.  .335. 


Fig.  336. 


Fig.  337. 


Fig.  338. 


Bone-cutting  pliers. 


Bone  forceps. 


Operative  Method. — The  instruments    retjuired  for  excisions  are: 
ordinary  dissecting  instruments,  retractors,  a   large-bellied  stout  scalpel. 


EXCISIOX    OF    JOIISTTS. 


517 


cartilage  knife,  bone  raspatory,  a  strong  hernia  bistoury  to  divide  liga- 
ments, blunt  bistoury,  various  bone  forceps  and  cutting  pliers,  a  Butcher, 
metacarpal,  Adams,  and  chain  saw,  stout  bone  gouges,  a  periostal  elevator, 


Fig. 


Chain  saw. 


curettes,  chisels  and  mallet,  drill,  and  bone  or  steel  nails.  Extra  large 
catgut  may  also  be  required  for  suturing  bones  together.  Avascularity 
should  be  secured  by  Esmarch's  rubber  band  if  the  joint  has  not  sup- 
purated; otherwise  simple  elevation  of  the  extremity  followed  by  the 


Fiu.  340. 


Forceps  for  grasping  large  bones. 

application  of  a  tourniquet  must  suffice,  for  the  danger  of  forcing  pus, 
etc.,  into  the  blood-current  is  considerable. 

Incisions  should  be  single,  as  straight  and  direct  as  possible,  avoid 
sinuses,  and  be  kept  away  from  important  bloodvessels  and  nerves.     Mus- 

FiG.  341. 


Adams's  osteotomy  saw. 


cles  should  not  be  cut  if  the  incision  can  be  carried  through  inter- 
muscular septse.  The  joint  having  been  laid  freely  open,  all  diseased 
tissues  are  eradicated.  So  far  as  the  bones  are  affected  they  should  be 
removed,  but  never  more,  especially  in  cases  of  epiphyses,  than  is  abso- 


518     DISEASES    OF    JOINTS,    CARTILAGES    AND    LIGAMENTS. 


lutely  necessary.  Experience  alone  can  teach  the  difference  between 
simple  congested  or  infianied  cancellous  tissue  and  that  which  harbors 
infectious  disease.     Often  diseased  foci  can  be  gouged  or  chiselled  out  of 

Fig.  342. 


Butcher's  excision  saw. 

the  medulla  without  further  sacrifice  of  the  shaft.  In  children  a  stout 
knife  will  often  do  the  work  of  a  saw.  The  value  of  epiphyses  should 
ever  be  kept  in  mind.     If  subsequent  bony  ankylosis  be  dcf^ired,  cancel- 

FiG.  343. 


Batcher's  excision  pliers. 

lated  tissue  must  be  exposed  upon  both  surfaces  of  the  joint.  All  por- 
tions of  the  irynovial  membrane,  other  affected  tissues,  and  sinuses,  must 
then  be  totally  eradicated  by  scissors,  curette,  knife,  or  cautery.  Sinuses 
should  be  bodily  excised,  when  possible.  If  deep  and  inaccessible,  a 
curette  should  be  carried  into  them  as  far  as  possible. 


Fig 


Barker-AViUanl  irr 


The  tourniquet  is  now  removed,  and  all  hemorrhage  stopped.  Bleed- 
ing from  bone  medulla  can  be  controlled  by  a  few  moments'  pressure 
with  a  finger  or  pad,  or  by  packing  in  a  small  wad  of  fine  catgut  and 
leaving  it.  C  arefully  wash  out  the  cavity,  insert  a  good-sized  rubber 
drain  in  large  joints  or  a  hank  of  catgut  into  small  ones,  restore  all  parts 
to  as  near  normal  position  as  possible,  suture,  dress  copiously,  place  the 
limb  upon  a  proper  splint,  and  always  keep  it  elevated  for  the  first  half 
day  or  so. 

Most  joints  can  be  so  excised  and  dressed  that  but  a  single  dressing 
completes  the  cure.  The  dressing  in  no  ca.se  should  be  changed  under 
three  or  four  weeks  or  more,  unless  there  are  distinct  indications  therefor. 


EXCISION    OF    JOINTS. 


519 


Where  fibrous  union  or  false  joint  is  required,  dressings  may  be  changed 
and  motion  be  commenced  in  four  weeks.  When  unabsorbable  drains 
are  left  in,  the  wounds  should  always  be  dressed  and  the  tubes  removed 
not  later  than  the  first  week. 

Some  form  of  mechanical  support  will  be  required  for  a  long  time  after 
many  excisions. 

Prognosis. — With  modern  methods  excisions,  when  early  undertaken, 
have  come  to  be  quite  safe  and  successful,  and  the  scope  of  the  operation 
has  become  correspondingly  extended.  Risk  of  operation  increases  as 
the  trunk  is  approached. 

Excision  of  Temporo-maxiUary  Joint. 

Excision  of  the  temporo-maxillary  joint  is  performed  by  making  a  one 
and  a  half  inch  vertical  incision  downward  from  a  point  just  behind  the 
middle  of  the  zygoma,  but  in  front  of  the  temporal  artery,  carrying  it 
down  through  the  masseter  muscle,  exposing  the  neck  of  the  jaw,  dividing 
it  with  Adams's  saw  or  cutting  pliers,  and  then  freeing  the  separated 
condyle  from  ligamentous  attachments.  Simple  osteotomy  of  the  neck 
of  the  bone  is  preferable  for  ankylosis  at  this  joint.  Temporary  palsy 
of  some  of  the  facial  muscles  may  follow  division  of  the  seventh  nerve 
fibres. 


Fig.  .345. 


Excision  of  Shoulder-Joint. 

Make  a  four-inch  vertical  incision,  beginning  at  the  anterior  tip  of  the 
acromion  process,  and  carry  it  downward  through  an  inter-fascicular 
partition  of  the  deltoid  until  the  capsule  is  opened 
and  the  humeral  shaft  exposed.  Free  the  deltoid 
from  its  capsular  attachments.  Divide  the  capsular 
attachments  of  the  head,  and  also  the  tendons  in- 
serted into  the  tuberosities,  rotating  the  arm  inward 
to  divide  the  then  tense  spinati  and  teres  minor 
attachments,  and  outward  for  the  subscapularis. 
Dissect  the  long  head  of  the  biceps  from  its  groove, 
and  hold  it  aside.  Throw  the  humeral  head  outside 
of  the  wound  by  carrying  the  elbow  across  the 
chest  toward  the  opposite  side  and  then  pressing  it 
upward  and  outward.  Saw  off  the  head  wuth  a 
Butcher's  or  other  saw,  and  trim  any  sharp  edges  or 
spiculfe  left.  If  a  common  amputating  saw  is  used, 
the  soft  parts  must  be  protected  by  a  disinfected 
strip  of  wood  or  hard  rubber.  Remove  all  diseased 
tissues,  gouge  out  the  glenoid  cavity,  or,  if  it  is  ex- 
tensively involved,  cut  it  away  with  pliers.  Wash 
out  the  cavity,  control  bleeding,  drain,  suture,  and 
dress  in  such  position  that  the  cut  extremity  of 
the  humerus  is  in  the  glenoid  cavity.  That  is,  get 
the  bone  into  position,  dress  and  bandage  as  for 
fracture  or  dislocation  in  the  same  locality.  Re- 
dress in  about  three  or  four  weeks,  and  then,  if  the  wound  is  sufi&- 
ciently  healed,  commence  passive  motion,  massage,  and  electricity.     A 


Excision  of  shoulder- 
joint.    Line  of  incision. 


520     DISEASES    OF    JOINTS,    CARTILAGES    AND    LIGAMENTS. 

verv  useful  arm  may  be  looked  for ;  the  muscles  shorten,  and  a  false 
joint  forms.  Abduction  will  be  much  impaired,  but  the  forearm  will  be 
as  gt)od  as  ever. 


Fig.  :ufi. 


\ 


Excision  of  Elbow-joint. 

The  arm  is  avascularized  by  the  rubber  band  or  elevation  and  tourniquet, 
slighth  Hexed  and  brought  over  a  pillow  or  block  with  the  olecranon  look- 
ing upward.  Incision  is  begun  two  inches  above  the  centre  of  the  olecranon 
and  carried  vertically  downward  four  inches,  bareing  the  humerus  above, 
the  ulna  lielow,  and  opening  the  joint  in  the 
centre.  The  articular  extremities  are  then  separ- 
ated from  their  muscular  and  ligamentous  attach- 
ments, great  care  being  observed  to  di.ssect  the 
ulnar  nerve  from  its  groove  on  the  inner  side  of 
the  joint  and  to  keej)  it  held  out  of  harm's  way 
during  the  subsequent  manipulations.  The  nerve 
is  gotten  out  by  slip])ing  a  director  into  the  canal 
from  above  and  dividing  the  outer  wall  upon  it. 
Now  the  olecranon  ])rocess  is  cut  from  the  ulna 
with  pliers,  the  lateral  ligaments,  if  still  present, 
are  divided  with  a  strong  hernia  knife,  and  by 
flexing  the  joint  the  remaining  bones  are  thrown 
outside  the  wound  and  sawn  off".  If  permissible, 
not  more  than  the  articular  surface  of  the  humerus, 
the  olecranon  above  the  coracoid  process  and  the 
radius  above  its  tubercle  should  be  taken  away. 
The  soft  parts  must  be  protected  whilst  the  saw- 
ing is  done.  Eradicate  all  diseased  surroundings, 
stop  hemorrhage,  irrigate,  suture,  drain,  dress  and 
•isioii.  place  the  arm  upon  an  obtuse  angle  splint  be- 

tween pronation  and  supination  to  secure  greatest 
Catgut  drains  will  often  answer  here.  Re-dress  in  three  or 
four  weeks  and  commence  motion.  At  the  elbow  false  or  movable  joint 
is  always  desired.     A  mechanical  ap))liance  must  usually  be  worn. 

If  no  more  bone  than  has  been  indicated  is  removed  the  result  will  be 
good  and  the  forearm  preserve  excellent  functions.  But  if  more,  espe- 
cially of  the  radius  and  ulna  is  taken  away,  power  of  flexion  is  obliter- 
ated by  removal  of  the  insertions  of  the  biceps  and  brachialis  anticus, 
and  rotation  nmch  interfered  with  ;  in  fact,  above  the  forearm  the  member 
will  be  useless,  although  below  that  point  all  will  continue  as  before. 


Excision  of   elbow-joint 
Line  of  incision. 


relaxation. 


Excision  of  Wrist-joint. 

By  excision  of  the  wrist-joint  is  meant  removal  of  the  ends  of  the 
radius  and  ulna  and  of  the  first  row  of  the  carpal  bones  ;  and,  perhaps, 
also  of  one  or  more  of  the  second  row,  or  even  of  the  metacarpal 
extremities.  Great  patience,  caution,  and  anatomical  knowledge  are  here 
requisite.  The  parts  are  rendered  avascular  and  an  incision  is  made 
beginning  at  or  upon  the  outer  surface  of  the  forearm  two  inches  above 
the  styloid  process  of  the  radius  at  a  point  just  inside  the  inner  margin 
of  the  extensor  communis  digitorum  and  carried  in  a  downward  and  inward 
direction  along  the  margin  of  that  muscle  and  the  tendon  of  the  extensor 


EXCISION    OF    JOINTS. 


521 


indicis,  until  about  the  centre  of  the  metacarpal  boue  of  the  index  finger 
is  reached.  The  flaps  are  now  -VTell  dissected  back  and  all  underlying 
tendons  running  over  the  joint  freed  from  their  sheaths  and  held  aside  by 
retractors.  If  the  jjisiform  bone  is  to  be  removed  the  attachment  of  the 
flexor  carpi  ulnaris  to  it  must  be  divided.  Occasionally  the  extensor 
carpi  radialis  longior  or  brevior  cannot  be  gotten  out  of  the  way,  so 
must  be  divided  and  the  ends  marked  by  threads  or  otherwise  for  subse- 
quent recognition  and  suture. 


Excision  of  wrist-joint.     Line  of  incision. 


Kg  tendons  should  be  cut  unless  positively  necessary,  but  when  so,  any 
number  may  be  freely  divided,  marked,  and  after  removal  of  the  bones 
sutured.  All  tendons  being  out  of  the  road,  the  radio-carpal  ligaments 
are  divided,  and,  by  strongly  flexing  the  hand,  the  radius  and  ulna  are 
thrown  out  of  the  wound.  Their  under  surface  is  then  freed  carefully 
from  tendons  and  nerves  and  the  necessary  amount  sawn  off.  The  hand 
is  then  brought  back,  the  inter- carpal  joint  opened  and  the  first  row 
of  bones  excised,  either  individually  or  en  masse,  great  caution  being 
observed  when  working  near  the  radial  artery. 

The  second  row  should  likewise  be  removed  if  diseased.  If  required, 
the  metacarpal  ends  can  be  cut  oft'  best  with  pliers.  The  synovial  mem- 
brane and  other  diseased  structures  are  then  carefully  removed,  the  cavity 
washed  out,  hemorrhage  controlled,  any  divided  tendons  sutured,  and  a 
drain,  dressing  and  palmar  splint  applied.  Passive  motion  of  the  fingers 
should  be  commenced  early. 

Excision  of  the  wrist  is  not  a  favorable  operation,  and  the  results  are 
often  wretched.  Still,  if  even  slight  use  of  the  fingers  is  retained,  the 
patient  will  value  the  member  much  more  than  an  artificial  limb.  Ex- 
cision may  be  performed  in  apparently  hopeless  cases,  and,  should  it  com- 
pletely fail,  amputation  can  be  done  after  the  member  has  been  given  a 
final  chance. 

Excision  of  any  jjarticular  bone  or  bones  of  the  carpus  may  be  made 
by  the  above  (but  more  curtailed)  incision,  or  by  one  directly  over  the 
affected  area. 


522     DISEASES    OF    JOINTS,    CARTILAGES    AND    LIGAMENTS. 

Krcisioit  of  metacarpal  proximal  extremities  can  be  made  by  a  one  and  a 
half  inch  vertical  incision  directly  over  the  joint,  through  which  pliers 
cut  oti'  the  extremity. 

Excision  of  Metacarpophalanr/eal,  and  Inter-  phalangeal  Joints. 

Excision  of  metacarpo-phalangeal  and  inter-phalangeal  joints  can  be 
performed  through  a  vertical  one  to  two-inch  incision  upon  the  upper 
aspect  of  articulation.  Articulating  extremities  are  separated  from  their 
bone  shafts  by  cutting  pliers  and  removed.  No  drain  is  required  as  a 
rule. 

Excision  of  Hip-joint 

Usual  Method. — The  patient  is  turned  upon  his  sound  hip,  and  the  oper- 
ator stands  facing  the  patient's  back.  Incision  is  begun  one  and  a  half 
inches  above  and  a  little  posterior  to  the  great  trochanter,  and  carried 
down  vertically  in  the  femoral  axis  for  a  distance  of  five  or  six  inches. 
The  bone  is  then  exposed  for  the  entire  distance.     Now  the  capsule  is 

Fig.  348. 


■""■nN; 

li^■~^-^  iii 


Excision  of  hip-joint.     Line  of  incision. 

freely  opened,  and  the  neck  of  the  femur  divided  transversely  by  an 
osteotomy  or  metacarpal  saw,  or,  if  in  a  young  child,  by  cutting  jDliers. 
The  head  of  the  bone  is  then  seized  by  lion-jaw  forceps,  the  round  ligament 
divided  if  it  still  remains,  and  the  separated  bone  removed.  All  possible 
diseased  structures  are  then  eradicated,  the  cotyloid  cavity  well  gouged  out 
and  irrigated,  all  bleeding  stopped,  a  large  drain  carried  to  the  bottom  of 
the  wound,  and  a  copious  dressing  applied.  Outside  this,  some  steadying 
apparatus,  such  as  a  plaster  dressing  to  the  whole  limb  and  chest,  exten- 
sion and  sand-bags  or  a  side  splint  must  be  applied  to  secure  perfect  sub- 
sequent rest  of  the  involved  parts.     Lateral  pressure  upon  the  wound  by 


EXCISION    OF    JOIXTS. 


523 


a  hip-band  or  sand-bag  is  advantageous  for  a  few  days  after  the  operation, 
as  also  is  moderate  elevation  of  the  limb  to  promote  muscular  relaxation 
and  drainage. 

As  much  more  of  the  femur  as  may  be  diseased  must  always  be  cut  off, 
after  separating  the  muscular  attachments  of  the  trochanters  and  inter- 
trochanteric line.  By  sparing  the  trochanter  minor  the  psoas  and  iliacus 
attachments  will  be  saved.  The  acetabulum,  if  diseased,  may  be  cautiously 
clipped  away.  A  high-heel  shoe  will  be  required  upon  the  affected  foot, 
and  usually  some  sort  of  a  leg-brace,  having  attachment  to  a  bodv  corset ; 

if  much  of  the  femur  has  been  taken 
Fig.  .349.  away,  crutches,  in  addition,  will  be 

required. 

Second  Method. — This  is  aj^plica- 
ble  to  cases  requiring  excision  in  the 
_^  earlier  stages  before  great  bone  de- 

struction has  taken  place  or  abscesses 


Excision  of  hip-joint  by  anterior  method. 
Line  of  incision.    (MacCoemac.) 


Excision  of  knee.     Line  of  incision. 


have  burst  through  the  capsule.  Incision  begins  upon  the  front  of  the 
thigh  half  an  inch  below  the  anterior  superior  iliac  spine  and  continues 
downward  and  a  little  inward  for  a  distance  of  three  inches.  In  following 
this  line,  the  knife  gains  free  access  to  the  capsule  and  joint  by  sinking 
between  the  tensor  vaginae  femoris  and  glutei  muscles  on  the  outside,  and 
the  rectus  and  sartorius  on  the  inner  side.     The  joint  is  then  opened  and 


524     DISEASES    OF    JOINTS,   CARTILAGES    AND    LIGAMENTS. 


irrigated,  the  saw  introduced,  and  the  femoral  neck  divided  in  the  direc- 
tion of  incision,  and  removed  after  division  of  the  round  ligament. 

Tlie  other  steps  of  operation  are  identical  with  the  method  already 
described. 

Excision  of  Knee-joint. 

This  joint  should  always  be  l)rought  into  as  extended  position  as  possible 
bv  gradual  pulley  extension  before  excision  is  undertaken  ;   otherwise 
niuch  bone  must  be  needlessly  sacrificed,  or  too  much  tension  excited  in 
bringing  it  straight  at  the  time  of  the  operation. 
The  extremity  having  been  made  as  straight 
as  possible  and  avascular,  an  incision  is  made  from 
a  point  in  the  centre  of  the  thigh  three  inches 
above  the  centre  of  the  patella  directly  downwai'd 
to  the  tubercle  of  the  tibia.     (Fig.  350.)     The 
flaps  are  then  held  back  and  the  patella  is  sawn 
through  vertically.     Next  the  quadriceps  and 
patellar  tendons  are  slit  to  their  full  extent,  the 
knee   still  further   l)ent,  and  one-half  of  the 
patella  and  its  attachments  pulled  to  each  side 
as  the  other  bones  of  the  joint  are  shot  out, 
and  the  crucial  ligaments  divided.     The  neces- 
sary amount  of  the  femoral  condyles  and  tibial 
head  (usually  about  half  an  inch  of  each)  are 
then  sawn  off  by  either  a   Butcher  saw  from 
without  inward,  or  by  an  amputating  saw  in 
the  opposite  direction.    In  the  latter  case  the 
contents  of  the   popliteal  space  must  be  pro- 
tected by  a  strip  of  hard  rubber  slipped  beneath 
the  bones.     Then    the   synovial  membrane  or 
diseased  cancellous  structures  are  eradicated  as 
usual,  all  the  remaining  cartilage  cut  away,  the 
tournicjuet  removed,  hemorrhage  controlled,  the 
bones  returned,  and  the  cavity  well   irrigated. 
After  reduction  of  the  bones,  the  patella  should 
be  dissected  out  if  found  diseased.     Care  must 
be  exercised  not  to  wound  the  popliteal  vessels 
whilst  sawing  or  cutting  away  affected  soft  parts. 
The  bones  may  be  nailed  together  by  steel  nails 
through  the  skin  after  the  parts  are  sutured,  but 
it  is  preferable  to  drill  holes  through  them  and 
into  these  insert  powerful   sutures   of  chromi- 
cized  catgut,  or  through  them  drive  ivory  or 
bone  nails,  so  as  to  fasten   the   bones  rigidly 
together.     The  patella  likewise,  if  not  diseased, 
is  sutured,  or  drilled  and  nailed,  and  the  split 
quadriceps  and  patellar  ligaments  are  united  by  catgut  stitches.    Drain- 
age is  to  be  assured  by  passing  tubes  through  openings  made  through  the 
skin  on  either  side  of  the  bottom   of  the  wound,  and  one  from  above, 
around  the  patella  into  the  subpatellar  region.     Copious  dressings  and  a 
long  posterior  si)lint  are  then  applied,  and  the  limb  kept  elevated  for 
several  days.     If  the  case  is  successful — that  is,  bony  union  and  ankylosis 
are  secured — the  patient  may  be  allowed  to  walk  in  from  eight  to  ten 
weeks.     Shortening  is  obviated  by  raising  the  appropriate  heel.    No  brace 
will  be  required  unless  bony  ankylosis  does  not  occur. 


EXCISION     OF    JOINTS. 


525 


Fig. 


Modifieaiions. — If  conditions  will  permit,  incision  may  be  made  along  the 
inside  of  the  tendons  and  patella  and  that  bone  and  its  attachments  slipped 
entire  to  the  outer  side  of  the  joint  when  the 
bones  are  shot  out.  Or,  if  disease  is  very  exten- 
sive, incision  can  be  made  transverse  and  the 
patella  sawn  through  in  the  same  direction.  In 
excision  for  deformity  incision  may  be  in  either 
direction,  the  flaps  separated,  and  a  sufficient 
wedge  to  correct  deformity  taken  from  the  anky- 
losed  bones  as  a  whole.  If  the  case  is  complicated 
by  contraction  of  the  hamstring  tendons,  or  if 
there  is  any  tension  upon  these  after  operation,  they 
should  be  divided  subcutaneously  with  a  tenotome. 

Excision  of  the  knee  is  almost  absolutely  safe  in 
properly  selected  cases  and  is  in  them  quite  certain 
to  yield  a  good  result  and  a  perfectly  serviceable 
limb. 

Excision  of  Ankle-joint. 

After  avascularization  an  incision  is  begun  three 
inches  above  the  external  malleolus  and  carried 
downward  along  the  posterior  margin  of  the  fibula, 
around  the  malleolus  and  forward  to  within  half 
an  inch  of  the  base  of  the  fifth  metatarsal  bone.  Bone  drill. 

The  flap  is  dissected  up  and  the  peronei  tendons 

divided.  The  lower  end  of  the  fibula  is  now  cut  with  saw  or  pliers 
and  the  external  malleolus  removed,  when  the  astragalus  comes  into 
view.  The  foot  is  then  inverted  and  the  upper  surface  of  the  astragalus 
sawn  off,  or  the  whole  excised  if  extensively  diseased.  Next  the  end 
of  the  tibia  is  cleared  of  all  attachments  and  the  necessary  amount 
sawn  off  and  removed.  If  this  cannot  be  readily  accomplished  through 
the  primary  incision  upon  the  inner  surface  of  the  foot,  another  incision 
running  around  the  internal  malleolus  and  terminating  at  the  cuneiform 
bone  should  be  made.  This  flap  is '  dissected  back,  the  tendons,  nerves, 
and  vessels  are  carefully  displaced  from  their  grooves  and  either  the  tibia 
shot  out  or  a  narrow-bladed  saw  inserted  behind  the  bone  and  made  to 
cut  from  behind  forward,  the  soft  parts  being  meanwhile  held  aside  and 
protected.  The  divided  portion  of  tibia  is  then  freed  from  attachments 
and  extracted  through  either  w^ound.  The  leg  and  foot  must  afterward 
be  kept  upon  a  right- angle  splint  or  in  a  fracture-box.  If  it  has  been 
necessary  to  divide  any  tendons  they  must  subsequently  be  sutured. 

The  results  of  ankle  excision  are  not  gratifying  so  far  as  subsequent 
usefulness  is  concerned,  although  the  wounds  heal  well  and  the  parts 
present  a  good  appearance.  Amputation  is  usually  the  preferable  measure 
at  this  joint. 


Excision  of  Metatarso-tarsal,  Metatarso-phalangeal,  and  Inter-phalangeal 

Joints. 

Excision  of  metatarso-tarsal,  metatarso-phalangeal,  and  inter-phalangeal 
joints  is  performed  in  the  same  manner  as  are  corresponding  excisions 
of  the  carpal  articulations.  But  as  the  digits  are  comparatively  useless, 
and  as  deformity  following  the  operation  may  impede  locomotion  or  pro- 
duce discomfort,  amputation  is  usually  to  be  preferred  to  excision. 


CHAPTER     XIX. 

RESPIRATORY  ORGANS. 

SURGICAL    DISEASES   AND    INJURIES   OF   THE    NOSE. 

Foreign  Bodies  in  the  Nose. 

Small  stones.  l)eads,  and  peas  are  occasionally  pushed  into  the  anterior 
nostrils  by  children  and  become  fastened  in  the  nasal  chambers.  Very 
rarelv  small  seeds  or  fruit  stones  may  get  into  the  posterior  nostrils  during 
vomiting.  Such  foreign  bodies,  if  allowed  to  remain,  set  up  inflamma- 
tion of  the  mucous  membrane  of  the  nose  and  give  rise  to  an  offensive 
discharge  which  sometimes  is  mistaken  for  grave  disease  of  the  nasal 
structures.  Foreign  b(»dies  should  be  removed  from  the  nasal  cavities  by 
a  small  hook,  such  as  comes  in  pocket  cases,  or  a  strabismus  hook  or  some 
similar  instrument.  It  is  usually  necessary  for  the  surgeon  to  illuminate 
the  nasal  cavities  by  means  of  a  forehead  mirror.  When  foreign  bodies 
cannot  be  removed  in  this  manner  they  may  be  washed  out  of  the  nostrils 
by  means  of  a  douche.  The  tube  of  the  douche  is  placed  in  the  nostril 
opposite  to  the  one  which  is  occluded,  while  the  patient's  head  is  bent 
forward  with  the  mouth  open.  The  stream  of  water  then  passes  around 
the  posterior  border  of  the  septum  and  into  the  closed  nostril  behind 
the  foreign  substance.  This  latter  is  then  washed  out  by  the  current 
coming  from  behind.  The  foreign  body  might  be  pushed  back  into  the 
pharynx  and  thus  removed,  but  there  is  danger  of  it  falling  into  the  glottis 
and  of  producing  asphyxia.  It  is  better,  therefore,  to  extract  such  sub- 
stances from  the  anterior  nares. 

Khinoliths,  or  nose  stones,  are  concretions  of  phosphate  of  lime  and 
mucus  which  sometimes  form  in  the  nose,  having  for  their  nuclei  small 
crusts  of  secretion  or  foreign  bodies.  These  rhiuoliths  should  be  removed 
in  the  same  manner  as  foreign  bodies.  If  they  are  large  they  can  be 
crushed  previously  with  a  pair  of  forceps. 

Epistaxis. 

Bleeding  from  the  nose  may  be  the  result  of  injury,  or  it  may  occur  as 
a  symptom  of  fibroid  or  malignant  tumors  in  the  no.se  or  pharynx.  It 
occasionally  occurs  spontaneously,  and  is  due  in  such  cases  to  congestion 
of  the  mucous  membrane ;  often  associated  at  the  time  with  congestion  of 
the  brain,  cirrhosis  of  the  liver,  granular  kidneys,  heart  disease,  scurvy, 
or  some  of  the  essential  fevei*s.  It  is  due  occasionally  to  impoverished 
condition  of  the  blood,  and  is,  as  is  well  known,  an  early  symptom  of 
typhoid  fever.  Bleeding  is  said  to  occur  at  times  from  small  ulcers  upon 
the  mucous  membrane. 

Epistaxis  is  usually  exhibited  by  an  escape  of  blood  from  the  anterior 
nostrils,  but  it  may  run  backward  into  the  pharynx  and,  getting  into  the 


EPISTAX13. 


527 


stomach,  be  subsequently  vomited,  giviug  the  appearance  of  htematemesis. 
It  may  get  into  the  larynx  and  be  coughed  up  in  a  red,  frothy  state  re- 
sembling haemoptysis.  Such  errors  are  avoided  by  examination  of  the 
pharynx  and  fauces  in  a  good  light.  When  the  blood  comes  from  the 
nose  it  will  be  seen  trickling  down  the  posterior  wall  of  the  pharynx. 

The  treatment  of  epistaxis  involves  the  consideration  of  the  causes' 
which  lead  to  its  occurrence  and  repetition.  The  visceral  factor  in  such 
bleeding  should  be  treated  by  appropriate  medical  means. 

Traumatic  epistaxis,  as  a  rule,  ceases  spontaneously  and  needs  no  treat- 
ment. It  should  be  remembered  also  that  in  cases  of  plethora,  in  which 
there  is  congestive  headache  or  other  symptoms  of  cerebral  eugorgement, 
bleeding  from  the  no§e  may  be  a  salutary  symptom.  Internal  remedies, 
such  as  gallic  acid,  preparations  of  lead,  ojiium  and  ergot,  are  given  to 
diminish  the  tendency  to  nose-bleeding,  but  are  of  little  value  at  the  time 
of  its  occurrence.  In  cases  of  moderate  severity  the  patient  should  be 
made  to  lie  down  with  his  head  considerably  elevated,  and  with  iced 


Fig.  353. 


Method  of  plugging  the  nares  from  in  front. 


cloths  applied  constantly  on  the  nose.  He  should  then  grasp  the  carti- 
laginous portion  of  the  nose  with  his  thumb  and  forefinger  in  such  a  way 
as  to  keep  the  nostrils  tightly  closed.  This  will  prevent  respiration 
through  the  nose  and  thereby  permit  clots  to  form,  thus  arresting  the 
flow  of  blood.  The  firm  pressure  by  the  fingers  prevents  the  access  of  air 
and  gives  an  opportunity  for  the  clots  to  close  the  bleeding  orifice.  It  has 
been  suggested  that  jDressure  with  the  finger  upon  the  facial  arteries  will 
limit  the  amount  of  blood  flowing  through  the  nose  and  aid  in  arresting 
hemorrhage. 

When  these  simple  measures  are  not  sufiicient  to  arrest  the  bleeding, 
and  the  patient  shows  signs  of  great  exhaustion  from  the  loss  of  blood, 
it  is  proper  to  plug  the  nose  upon  the  side  which  is  bleeding.     This  may 


528  RESPIRATORY    ORGANS. 

by  (lone  by  passing'  a  long  and  narrow  rubber  bag,  from  which  the 
air  has  been  expelled,  along  the  Hoor  of  the  nares  so  that  it  will  extend 
from  the  anterior  nostril  to  the  posterior   nostril,  and  inflating  it  with 

air.     Pres.sure  is  thus  made  upon  the  walls 
f"'*'-  "'^"*-  of  the  nasal  cavities. 

The  most  effectual  means  of  plugging  the 
nostrils  is  by  means  of  small  pieces  of 
sjjonge  threaded  upon  a  strong  cord.  The 
proper  method  of  doing  this  is  to  tie  a  piece 
of  antiseptic  sponge,  about  as  large  as  a 
India-rubber  inflating  tampon  for  good-sized  marble,  tothe  end  of  a  piece  of  silk 
plugging  the  nares.  ligature.     The  spongg  is  then  pushed  along 

the  floor  of  the  naris  until  it  reaches  the 
posterior  opening  of  the  nasal  cavity.  That  it  has  been  pushed  all  the 
way  back  can  be  determined  by  the  length  of  the  string,  or  by  the  surgeon 
putting  his  finger  into  the  pharynx.  When  this  first  piece  of  sponge  has 
been  properly  placed,  a  single  string  will  hang  out  of  the  anterior  nostril. 
A  similar  piece  of  sponge  with  a  hole  in  the  middle  should  now  be 
threaded  upon  this  string  and  crowded  back  by  means  of  the  forceps  into 
the  nasal  chamber.  By  thus  packing  with  successive  pieces  of  sponge  the 
whole  nasal  chamber  from  the  anterior  to  the  posterior  opening,  bleeding 
is  absolutely  prevented  by  pressure  of  the  sponge  completely  filling  the 
nasal  cavity.  The  sponge  may  be  allowed  to  remain  in  place  for  from 
twenty-four  to  forty-eight  hours.  If  the  nose  has  been  thoroughly  washed 
out  previously  with  an  antiseptic  solution,  which  of  course  must  be  of  the 
non-poisonous  kind,  and  if  the  sponges  and  silk  are  thoroughly  antiseptic, 
there  is  little  danger  of  putrefaction  even  when  the  packing  is  allowed  to 
remain  for  a  longer  time.  Usually,  however,  from  thirty-six  to  forty-eight 
hours  is  sufficient  to  preclude  the  possibility  of  recurrence  of  the  hemor- 
rhage. This  method  is  far  superior  to  the  use  of  Bellocq's  canula,  or  any 
modification  of  the  principle  by  which  a  string  is  brought  out  of  the 
mouth  after  being  attached  to  a  plug  thrust  up  behind  the  soft  palate. 

y^asal  Catarrh, 

The  term  nasal  catarrh  is  used  to  indicate  inflammation  of  the  mucous 
membrane  of  the  nasal  cavities.  It  usually  shows  little  or  no  ulceration. 
There  are  three  forms. 

1.  Simple  nasal  catarrh,  in  which  there  is  a  thin  mucous  or  muco- 
purulent discharge  without  thickening  of  the  mucous  membrane  and 
without  incrustation  of  secretion  or  fetid  odor. 

2.  The  hypertrophic  form,  in  which  the  mucous  membrane,  especially 
that  over  the  turbinated  bones,  is  swollen  and  infiltrated  with  inflamma- 
tory deposits,  and  in  which  there  is  a  change  of  voice  and  formation  of 
crusts  within  the  nose. 

o.  The  atrophic  form,  often  called  dry  catarrh,  in  which  there  is 
atrophy  of  the  glands  of  the  mucous  membrane,  so  that  the  nasal  cavities 
are  enlarged  beyond  the  normal  condition,  and  are,  of  course,  larger  than 
is  the  case  during  the  existence  of  hypertrophic  catarrh,  in  which  the 
mucous  membrane  is  swollen.  The  atrophic  form  is  accompanied  by 
great  fetor,  and  seems  to  be  a  stage  following  the  hypertrophic  condition. 

Offensive  odor  does  not  seem  to  be  a  characteristic  of  hypertrophic 


SURGICAL    DISEASES    AND    INJURIES    OF    THE    NOSE.      529 

catarrh,  unless  atrophy  has  begun  in  some  portion  of  the  diseased  mucous 
membrane. 

The  term  ozaena  is  often  indefinitely  used  by  surgeons  to  indicate  the 
existence  of  a  fetid  nasal  discharge.  The  term  should  be  discarded,  how- 
ever, because  such  fetid  discharge  may  occur  in  atrophic  catarrh  and  in 
tubercular  or  syphilitic  disease  of  the  nose,  as  well  as  from  foreign  bodies 
impacted  in  the  nostrils,  and  from  other  causes.  Since  the  term  ozsena 
conveys  no  idea  of  the  pathological  condition,  it  should  not  be  employed. 
A  head  mirror  and  speculum,  or  rhinoscope,  are  necessary  for  the  correct 
determination  of  these  various  conditions. 

Treatment. — The  treatment  of  nasal  inflammations,  except  when 
due  to  syphilis  or  gonorrhoea,  is  not  very  satisfactory,  except  in  the  hands 
of  a  specialist.  Various  forms  of  sprays  thrown  into  the  nose  by  means 
of  an  atomizer  are  valuable  ;  and  local  treatment  of  various  kinds  applied 
directly  to  the  diseased  area  are  the  most  efficient  means.  Constitutional 
treatment  is  required  to  aid  these  local  measures,  since  nasal  disease  may 
depend  upon  syphilis,  tuberculosis,  and  other  conditions  leading  to  bad 
health  ;  but  too  much  stress  cannot  be  laid  upon  the  necessity  for  efficient 
local  treatment.  Hypertrophied  tissue  may  be  removed  by  the  snare,  or 
by  the  application  of  the  galvano-cautery,  or  the  curette. 

Nasal  Polyps. 

Tumors  occurring  within  the  nasal  cavities,  as  sessile  or  pedunculated 
masses,  are  called  polypi  or  polyps.  The  most  common  form  of  polypus 
is  the  myxoma,  although  fibroma,  sarcoma,  and  carcinoma  are  not  very 
infrequent. 

The  myxoma  is  the  one  meant  when  the  term  polypus  is  ordinarily 
used.  These  polypi  are  soft,  gelatinous,  semi-translucent,  pinkish  or 
yellowish-white  masses,  which  have  their  attachment  to  the  mucous  mem- 
brane in  the  neighborhood  of  the  upper  or  middle  turbinated  bones ; 
although  they  may  arise  in  the  antrum  and  other  cavities  connected  with 
the  nose.  They  seldom  grow  from  the  roof  or  septum  of  the  nasal 
chambers,  are  generally  covered  with  ciliated  epithelium,  and  are  mul- 
tiple, although  one  or  two  of  the  group  generally  exceed  the  others  in 
size.  In  shape,  they  may  vary  from  the  globular  to  the  pyriform  or 
ovoid  form. 

Symptoms. — The  respiratory  obstruction  due  to  the  condition  causes  a 
change  in  the  tone  of  the  voice,  giving  it  the  so-called  nasal  sound.  The 
interference  with  respiration  is  increased  in  damp  weather,  because  the 
tumor  swells  from  absorption  of  moisture.  An  increased  feeling  of  stuffi- 
ness in  the  nose  therefore  occurs  under  such  circumstances.  There  is 
considerable  nasal  discharge,  which  is  usually  not  ofiensive ;  some  frontal 
headache  at  times,  and,  possibly,  impairment  of  the  sense  of  smell.  The 
patient  is  apt  to  be  continually  snuffling,  because  of  the  interference  with 
respiration  and  the  flow  of  mucus.  Obstruction  of  the  tear-duct  may 
occur  secondarily,  and  the  bones  of  the  nose  may  be  pushed  out  of  place, 
so  that  the  bridge  of  the  nose  is  widened  by  the  pressure  of  the  internal 
tumors.     Reflex  cough  and  asthma  have  been  attributed  to  nasal  polypi. 

Diagnosis. — Inspection  of  the  interior  of  the  nose  will  usually  make 
the  diagnosis  clear,  since  hypertrophy  of  the  mucous  membrane  and  the 
other  forms  of  nasal  polypi  show  redness  of  the  surface,  very  different 
from  the  yellowish  pearly  color  of  a  mucous  polypus. 

34 


530  RESPIRATORY    ORGAN'S. 

If  tlie  tumors  occupy  a  high  situation,  or  if  they  are  not  very  largely 
distended  by  the  absorption  of  moisture,  it  may  l)e  difhcult  to  see  them 
unless  a  speculum  is  use<l  in  the  anterior  nares,  or  a  rhinoscope  employed 
for  the  examination  of  tlie  posterior  nares.  The  surgeon,  by  introducing 
his  finger  into  the  mouth  and  carrying  its  tip  behind  the  soft  ])alate,  may 
sometimes  be  able  to  feel  a  mass  protruding  from  the  posterior  nares  into 
the  pharynx. 

Tkkatmknt. — Extirpation  of  the  tumors  is  the  proper  treatment,  and 
mav  be  done  by  the  galvano-ecraseur,  or  by  avulsion  with  forceps.  The 
cautery  gives  less  pain  and  loss  of  blood,  but,  in  any  event,  bleeding  is 
not  important  and  the  pain  need  not  be  severe;  the  latter  can  be 
obviated  by  painting  or  spraying  the  interior  of  the  nose  with  a  solution 
of  cocaine.  When  the  surgeon  desire-  to  pull  out  a  myxomatous  polypus 
with  the  polypus  forceps,  this  instrument  should  be  introduced  into  the 
nose  in  such  a  manner  that  the  blades  open  vertically  ;  they  should  then 
be  pushed  uj)  until  the  gelatinous  masses  can  be  seizectnear  their  pedicles 
and  pulled  from  their  attachments  by  twisting.  The  base  may  be  cauter- 
ized with  the  galvano-cautery  or  some  chemical  agent.  If  the  polypus 
protrudes  from  the  posterior  nares,  a  force})s  introduced  by  the  mouth 
may  sometimes  be  effective. 

Intra-nasal  Hbroid  j)olyps  usually  arise  from  the  posterior  part  of  the 
septum  or  from  the  superior  turbinated  bone,  and  may  project  into  the 
pharynx,  antrum,  or  pterygo-maxillary  fissure.  It  may  occur  that  the 
growth  will  force  its  way  into  the  orbit,  into  the  cranium,  or  out  upon 
the  cheek,  having  previously  caused  absorption  of  the  bony  walls  of  the 
nasal  cavity.  Such  fibroid  tumors  may  develop  in  the  pharynx  and  grow 
into  the  nasal  cavity,  or  they  may  extend  from  the  nose  into  the  pharynx, 
thus  obtaining  in  both  cases  the  name  of  naso-pharyngeal  polypi.  When 
such  a  growth  has  obtained  considerable  bulk  it  is  impossible  to  determine 
whether  it  has  had  its  origin  within  the  nose  or  in  some  of  the  adjacent 
cavities. 

Obstruction  due  to  fibroid  polypus  is  more  marked  than  that  due  to 
the  myxomatous  variety;  and  the  tumor  is  distinguished  by  its  hardness, 
redness,  and  tendency  to  bleed,  and  by  the  fact  that  its  bulk  is  not 
changed  by  damp  weather.  This  form  of  polypus  occui-s  most  commonly 
in  young  adults.  It  is  treated  by  avulsion,  ligation,  or  excision.  The 
galvano-ecraseur  may  be  found  very  useful  in  removing  moderate  sized 
fibroid  polyps. 

When  these  growths  have  obtained  considerable  size  it  becomes  neces- 
sary, if  removal  is  desirable,  to  separate  the  nose  from  the  face  and  turn 
down  the  organ,  or  to  gain  access  to  the  tumor  by  splitting  the  upper  lip 
and  turning  the  ala  out  of  the  way.  The  upper  jaw  may  in  other  instances 
be  cut  loose  and  turned  outward  so  as  to  give  access  to  the  naso-pharyn- 
geal cavity,  or  the  soft  and  hard  palate  may  be  split  with  the  aid  of  a  saw 
or  chisel.  These  operations  may  be  undertaken  because  of  the  obstruc- 
tion which  the  growth  causes,  or  because  of  bleeding  from  it  which 
threatens  the  patient's  life.  It  is  ju.stifiable  to  adopt  such  radical  meas- 
ures because  of  the  non-malignant  character  of  the  tumor;  whereas  if  it 
was  known  to  be  a  malignant  tumor  such  operations  would  perhaps  be 
improper  since  complete  removal  would  be  scarcely  possible. 

It  is  stated  that  such  growths  sometimes  atrophy  in  patients  reaching 
middle  life,  and  that  an  operation  which  simply  cuts  away  a  portion  of 
the  tumor  is  preferable  to  the  major  operations.     Ligation  of  the  two 


SURGICAL    DISEASES    AND    INJURIES    OF    THE    NOSE.       531 


external  carotid  arteries  has  been  practised  in  order  to  cut  off  the  blood 
supply  to  the  fibroma  within  the  nose  and  thus  assist  in  its  shrinkage. 

Malignant  polypi,  which  are  sarcomatous  or  carcinomatous,  increase 
rapidly,  soon  infiltrate  the  surroundiug  tissue,  which  undergoes  ulceration, 
and-  produce  involvement  of  the  lymphatic  glands.  If  operation  is  not 
undertaken  very  early  it  is  usually  futile.  Recurrence  is  frequent,  even 
after  prompt  interference. 

Adenoid  Vegetations  in  the  Pharynx. 

In  the  vault  of  the  pharynx  there  occur  during  childhood  growths  of 
adenoid  tissue  somewhat  similar  to  the  hypertrophy  of  the  tonsils,  which 
is  not  uncommon  at  a  similar  age.  This  pedunculated,  sessile,  or  fringe- 
like growth  obstructs  the  breathing,  impairs  the  quality  of  the  voice,  and 
interferes  with  the  hearing.  It  is  also  apt  to  be  associated  with  nasal  and 
pharyngeal  catarrh,  or  enlargement  of  the  tonsils.  The  hypertrophic 
masses  may  be  felt  with  the  finger  passed  into  the  pharynx  and  are  apt  to 
bleed  when  manipulated.  The  obstruction  to  respiration  causes  the  child 
to  breathe  through  the  mouth,  and  leads  to  symptoms  pertaining  to  mouth 
respiration.  These  adenoid  vegetations  may  atrophy  as  the  child  increases 
in  age,  but  it  is  often  necessary  to  remove  them  with  forceps  or  curette 
because  they  induce  deafness.  The  rhinoscope  or  head  mirror  is  necessary 
in  these  ojDerations.  Astringent  applications  may  be  of  some  service  in 
mild  cases. 

Deformities  of  the  Nose. 

Deformity  of  the  nose  may  be  congenital  or  the  result  of  injury.  Oc- 
casionally, as  a  result  of  injury,  a  blood  tumor  forms  between  the  mucous 
membrane  of  the  septum  and  the  cartilage  or  bone  forming  that  partition. 
These  submucous  collections  of  fluid  resemble  abscess  of  the  septum  and 
appear  as  soft  swellings  of  the  mucous  membrane.  Abscess  is  similar  in 
appearance,  but,  as  a  rule,  it  follows  signs  of  inflammation.  Abscess  of 
the  septum  should  be  treated  by  incision.  These  bloody  extravasations, 
however,  are  usually  slowly  absorbed. 

Occasionally  bony  or  cartilaginous  tumors  grow  upon  the  septum ; 
they  are  usually  near  the  floor  of  the  nostrils.  Such  growths  may  even 
extend  across  the  nasal  chamber  and  come  in  contact  with  the  lower  tur- 
binated bone,  forming  a  sort  of  bridge  within  the  nose.  It  is  not  unusual 
for  the  septal  cartilage  to  be  more  or  less  deformed,  either  congenitally  or 
as  a  result  of  traumatism.  Such  deviation  of  the  septum  as  well  as 
the  cartilage  and  bone  tumors  above  spoken  of,  may  lead  to  injurious 
obstruction  which  will  require  operation. 

Fig.  355. 


Diagram  of  deformities  of  nasal  septum  from  author's  "  Cure  of  Crooked  Noses." 

Deformity  due  to  syphilitic  necrosis  of  the  iutra-nasal  structures  is 
apt  to  show  itself  in  depression  of  the  bridge  of  the  nose  which  causes 
the  tip  of  the  nose  to  appear  as  a  small  elevation  or  knob  upon  the  ante- 


532  RESPIRATORY    ORGANS. 

ri»ir  portion  of  the  face.  The  entire  nose,  or  a  very  large  portion  of  it, 
may  similarly  be  lost  from  syphilitic  ulceration.  Portions  of  the  nose 
may  be  alt^o  removed  by  wounds,  and,  tlierefore,  require  reconstruction. 

rm[)roperly  or  carelessly  treated  fractures  of  the  njvsal  bones  and  carti- 
lage often  give  rise  to  very  unsightly  deformities  of  the  nose,  causing  it 
to  have  a  bent  or  twisted  appearance  or  to  be  the  site  of  some  unbecom- 
ing projection.  The  surgeon  is  often  rec(uired  to  treat  such  mal-forma- 
tions,  and  may,  by  judicious  measures,  restore  the  deformed  outline.  It 
is  very  difficult,  however,  to  improve  the  appearance  of  a  nose  in  which 
the  bridge  is  sunken  as  a  result  of  bone  disease,  or  of  congenital  defi- 
ciency in  development.  A  number  of  more  or  less  complicated  opera- 
tions have  been  devised  for  this  purpose  and  are  to  a  certain  degree 
successful. 

A  cartilaginous  or  bony  tumor  growing  from  the  septum  should  be 
chiselled  or  sawe  1  away,  as  the  obstruction  leads  to  breathing  through 
the  mouth,  a  disagreeable  tone  of  voice,  and  often  to  nasal  catarrh.  If 
the  septum  is  deviated  to  any  marked  extent  it  should  be  put  into  place 
by  fracturing  it  with  a  strong  forceps,  or  by  incisions  made  into  it  with  a 
small  knife,  and  subsequently  be  retained  there  by  pins.  .  If  the  devia- 
tion involves  a  large  portion  of  the  septal  cartilage,  the  cartilage  should 
be  made  flaccid  by  a  number  of  incisions  cut  in  it  with  a  stellate  nose- 
punch  before  it  is  pinned  into  its  new  position.  The  point  of  a  pin, 
which  should  be  from  one  and  a  quarter  to  one  and  a  half  inches  long,  is 
then  introduced  into  the  more  open  nostril,  after  the  septum  has  been 
broken  or  cut  and  made  flaccid,  and  its  point  thrust  through  the  anterior 
part  of  that  portion  of  the  septal  cartilage  which  the  surgeon  wishes  to 
control  and  keep  in  its  new  relation  to  the  other  portions.  This  part  is 
pressed  into  the  desired  position  and  the  point  of  the  pin  is  then  thrust 
forward  through  the  other  chamber  of  the  nose  and  its  point  firmly 
buried  in  the  tissues  at  the  back  part  of  this  second  nostril.  By  this 
device  the  divided  septum  is  firmly  held  in  its  new  position  as  shown  by 
the  diagram.  The  head  of  this  pin  will  be  just 
Fig.  356.  inside  of  the  anterior  naris  and  must  be  allowed 

to  remain  for  a  week  or  ten  days  before  it  is 
Avithdrawn.  It  is  often  well  to  introduce  a 
second  pin  from  the  external  surface  of  the 
front  of  the  nose  just  below  the  nasal  bone. 
This  aids  in  keeping  the  septal  cartilage  and 
bone  in  proper  place.  The  second  pin  should 
have  a  flat  head  so  that  it  may  lie  close  to  the 
surface  of  the  nose  and  be  covered  with  a  small 
square  of  court  plaster. 
Author's  method  of  pinuing  iSubmucous  resection  of  the  septal  cartilage 
nasal  septum.  ^ji(^[  bony  septum  is  the  best  method  of  curing 

nasal  obstruction  when  due  to  a  limited  deflec- 
tion of  the  partition  between  the  nares.  The  mucous  membrane  is  incised 
and  lifted  up  from  the  septum,  so  that  a  tenotome  or  small  saw  can  be 
used  to  cut  out  the  deflected  cartilage  and  bone.  The  flap  or  curtain  of 
mucous  membrane  is  then  allowed  to  drop  over  the  opening  in  the 
septum. 

If  the  organ  is  greatly  distorted  by  reason  of  old  fracture,  the  soft 
tissues  may,  with  a  tenotome,  be  pared  loose  from  the  bones  and  the  ex- 
ternal nasal  structures  be  twisted  into  place  after  the  .septum  has  been 
divided  and  before  the  pin  has  been  introduced.     By  proper  pinning,  the 


ABSCESS    OF    THE    ANTRUM.  533 

nose  can  often  be  kept  in  the  median  line  and  a  fairly  normal  contour 
re-established. 

This  operation  is  always  very  bloody  and  requires  etherization.  The 
pinning  method  is  much  better  than  the  use  of  plugs  to  retain  the  parts 
in  position,  since  they  do  the  work  more  effectually  and  leave  the  nostrils 
free  so  that  an  antiseptic  solution  can  be  used  for  washing  out  the  nose 
during  the  period  of  inflammation  after  operation. 

The  reconstruction  of  portions  of  the  nose  which  have  been  lost  is 
called  rhinoplasty.  The  most  common  cause  of  this  condition  demand- 
ing such  operative  procedures  is  loss  of  the  nasal  structures  from  syphilis. 
A  columella  may  be  made  by  cutting  a  piece  from  the  centre  of  the 
upper  lip  and  turning  it  up,  so  that  it  may  be  sutured  to  the  septal  car- 
tilage and  the  tip  of  the  nose  between  the  two  nares.  An  ala  may  be 
made  by  turning  into  the  gap  a  flap  dissected  up  from  the  cheek  or  upper 
lip.  A  tip  of  the  nose,  or  even  a  new  bridge  may  be  constructed  from 
the  point  of  a  finger  which  has  previously  been  freshened,  sutured  to  the 
nose,  and  kept  in  that  position  by  gypsum  bandages  around  the  arm  and 
head  for  several  weeks. 

Total  rhinoplasty  may  be  effected  by  turning  down  a  large  flap  from 
the  forehead.  This  is  called  the  Indian  method  of  rhinoplasty  in  con- 
trast to  the  Italian  method,  in  which  a  large  flap  is  taken  from  the  upper 
arm. 

Abscess  of  the  Antrum. 

Suppuration  within  the  antrum  may  be  incidental  to  dental  irritation, 
to  tumor,  to  syphilitic  necrosis,  etc.  One  or  more  of  the  upper  teeth  may 
have  their  roots  penetrating  the  antral  cavity ;  hence  caries,  or  other 
disease  of  such  teeth,  may  lead  to  inflammation  and  suppuration  of  the 
mucous  membrane  lining  the  antrum.  Suppuration  occurring  here,  as  it 
does,  within  a  normal  cavity,  is  properly  called  a  purulent  effusion.  The 
pus,  as  a  rule,  escapes  through  the  nose  or  through  the  diseased  tooth- 
socket  ;  hence,  symptoms  due  to  retention  of  pus  in  the  quasi-abscess 
cavity  are  not  very  common.  When  the  pus  cannot  escape,  however, 
swelling  of  the  cheek,  protrusion  of  the  eyeball,  occlusion  of  the  tear- 
duct,  stoppage  of  the  nostril,  and  bulging  downward  of  the  hard  palate 
arise  from  this  condition  of  the  antrum,  as  in  tumors  occupying  it. 

Sometimes  the  walls  of  the  antrum  are  so  thinned  by  the  inflammatory 
process  that  pressure  upon  the  cheek  may  develop  crackling  similar  to 
that  which  occurs  in  cystic  tumors  of  the  lower  jaw  as  well  as  in  tumors 
of  the  upper  jaw.  Fluid  within  the  antral  cavity  may  sometimes  be 
diagnosed  by  percussion  on  the  cheek  over  the  diseased  bone,  which  will 
develop  a  percussion  note  different  from  that  found  over  the  bone  on  the 
opposite  side.  When  antral  pus  does  not  find  vent  through  a  tooth-socket 
or  through  the  opening  into  the  middle  meatus  of  the  nose,  pointing  may 
occur  upon  the  cheek  or  in  the  roof  of  the  mouth. 

The  treatment  of  pus  in  the  antrum  consists  in  puncturing  the  bone 
below  the  upper  lip  above  the  canine  tooth,  or  by  extracting  the  tooth,  if 
it  is  badly  diseased,  which  seems  to  have  its  fang  extending  upward  into 
the  cavity  of  the  jaw.  The  antral  wall  of  the  upper  jaw  is  so  thin  that 
it  can  be  perforated  with  a  strong  knife  and  treated.  The  cavity  should 
then  be  washed  out  with  carbolic  or  beta-naphthol  solution.  The  opening 
in  the  bone  should  be  kept  patent  by  frequent  washing  by  means  of  a 
syringe,  and,  possibly,  by  the  continuous  wearing  of  a  metal  stile  or  plug 


534  RESPIRATORY    ORGANS. 

SO  as  to  prevent  occlusion  of  the  oriHce  made  for  drainage.  During 
eating,  a  little  piece  of  cotton  may  be  put  into  the  opening  in  order  to 
prevent  the  entrance  of  food,  if  the  retention  of  a  stile  or  plug  is  not 
enforced. 

Suppuration,  similar  to  that  which  occurs  in  the  antrum,  may  at  times 
occur  in  the  mucous  sinus  of  the  frontal  bone  and  re<(uire  evacuation  by 
trephining  the  bone  at  the  root  of  the  nose. 

Diseases  of  the  Air-passages. 

(Edema  of  the  Glottis. 

Swelling  of  the  mucous  membrane  of  the  larynx  or  of  the  folds  between 
the  epiglottis  and  the  arytenoid  cartilages,  due  to  inflammation  or  to 
dropsy,  resulting  fi'oni  Bright's  disease  of  the  kidneys,  may  give  rise  to 
serious  obstruction.  This  wdema  of  the  glottis,  when  of  an  inHammatory 
kind,  may  arise  from  the  inhalation  of  hot  steam,  the  swallowing  of  acids 
and  other  irritating  substances,  insect  stings,  or  to  idiopathic  laryngitis. 

The  treatment  of  this  condition,  when  asphyxia  is  too  immediate  to 
allow  delay  for  medical  remedies,  is  scarification  of  the  swollen  mucous 
membrane  by  means  of  a  curved  knife  introduced  through  the  mouth. 
The  tongue,  during  the  operation,  can  be  held  down  by  means  of  a  tongue 
depressor,  or  by  the  finger  of  the  surgeon.  Opening  the  larynx  in  the 
crico-thyroid  space  may  be  recpiired  to  prevent  suffocation  in  severe  cases, 
which  the  surgeon  fears  to  leave  unattended  between  his  visits. 

Fracture  of  the  Larynx  and  Trachea. 

The  laryngeal  cartilages  and  rings  of  the  trachea  may  be  broken  by 
blows  upon  the  throat,  as  from  a  base-ball  or  in  attempts  at  homicidal 
throttling.  It  is  usually  the  thyroid  cartilage  w'hich  is  severely  fractured. 
In  such  injuries  the  vocal  cords  may  be  dislocated  and  death  ensue  at 
once  from  asphyxia,  due  to  spasm  of  the  glottis.  Suffocation  may  like- 
wise occur  from  hemorrhage,  as  a  result  of  laceration  of  the  mucous 
membrane  lining  the  larynx.  Such  laceration  will  probably  be  indicated 
by  the  coughing  up  of  bloody  mucus.  It  is  wise  to  perform  tracheotomy 
in  all  cases  of  bad  fracture  of  the  larynx  and  trachea,  because  of  the 
great  danger  of  sudden  death  being  caused  by  rapid  inflammatory  swell- 
ing of  the  intra-laryngeal  structures,  or  to  emphysema  under  the  mucous 
membrane  and  in  the  tissues  of  the  throat.  The  broken  cartilage  can  at 
times  be  held  in  place  by  the  application  of  adhesive  plaster  on  the  out- 
side of  the  throat.  Better  apposition,  however,  can  be  obtained  by  cutting 
down  upon  the  injured  cartilages  and  uniting  them  properly  by  means  of 
catgut  or  silk  sutures. 

Foreign  Bodies  in  the  Air-passages. 

Foreign  bodies  can  gain  entrance  to  the  larynx  and  trachea  only  when 
the  glottis  is  opened.  Contact  with  the  margin  of  the  glottis  induces 
instant  spasm,  which  closes  the  chink  and  prevents  admission  of  any 
intruding  substance ;  hence,  foreign  bodies  can  only  pass  into  the  air- 
passages  when  the  glottis  is,  as  it  were,  surprised.  Accordingly,  foreign 
substances  usually  get  into  the  air-passages  when  there  is  sudden,  violent 


DISEASES    OF    THE    AI  E-P  A  SS  A  GE  S.  535 

iDspiration  made  at  a  time  when  the  patient  is  holding  a  pebble,  a  bean, 
or  some  such  substance  in  the  mouth.  Coins  thrown  up  in  the  air  to  be 
caught  in  the  mouth  sometimes  slip  through  the  chink  of  the  glottis. 
Food  and  intestinal  worms,  which  have  been  regurgitated  or  vomited  into 
the  upper  part  of  the  pharynx,  may  occasionally  find  their  way  into  the 
larynx  and  trachea.  Bodies  so  admitted  into  the  air-tract  may  be  caught 
between  the  vocal  cords  and  detained  in  the  larynx,  or  after  passing  be- 
yond this  point  may  lie  loose  in  the  trachea  or  even  get  down  into  the 
bronchus.  The  right  bronchus,  being  in  a  more  direct  line  with  the  wind- 
pipe than  the  left,  is  the  tube  in  which  foreign  bodies,  going  lower  than 
the  trachea,  usually  become  lodged. 

Foreign  substances  impacted  in  the  larynx  at  once  give  rise  to  violent 
spasm  of  the  glottis,  by  which  the  patient  may  be  immediately  sufibcated. 
The  lividity  of  countenance,  the  gasping  for  breath,  and  the  shrieks  of 
the  patient  are  followed  by  foaming  at  the  mouth,  insensibility,  and  sud- 
den apncea.  If  the  foreign  body  is  small  enough  to  permit  the  passage 
of  air  alongside  of  it,  death  may  not  occur  even  if  it  is  impacted  in  the 
larynx  ;  and  the  first  spasm  of  respiration,  which  has  just  been  described, 
may  subside  and  the  patient  regain  consciousness.  Aphonia  is  character- 
istic of  the  impaction  of  such  small  foreign  bodies  in  the  laryngeal  cavity. 
Spasm  of  the  glottis  in  such  cases  occurs  at  irregular  times,  in  any  one  of 
which  death  may  take  place.  A  period  of  irritation  succeeds  the  obstruc- 
tive period,  and  is  characterized  by  pain,  coughing,  and  expectoration  of 
blood-stained  mucus.  These  irritating  symptoms  are  especially  prominent 
if  the  body  has  sharp  edges,  and  occur  when  the  foreign  body  is  in  the 
trachea  and  bronchus,  as  well  as  when  it  is  impacted  in  the  larynx. 
Bodies  loose  in  the  trachea  may  produce  violent  symptoms.  They  are 
liable  to  be  coughed  up  against  the  lower  surface  of  the  vocal  cords  and 
cause  spasmodic  asphyxia,  in  which  the  fatal  end  may  occur,  or  they  may 
at  such  times  become  impacted  in  the  larynx.  The  symptoms  are  similar 
to  those  already  described.  The  patient  is  cyanosed,  and  often  is  more 
comfortable  in  the  sitting  posture  than  in  the  recumbent  one.  There  is, 
perhaps,  feebleness  in  respiratory  sounds  on  auscultation,  which  is  espe- 
cially marked  on  one  side  of  the  chest  when  the  corresponding  bronchus 
contains  the  foreign  body.  From  the  occurrence  of  secondary  bronchitis 
various  rales  may  be  heard  in  the  lungs.  In  some  instances  a  peculiar 
whistling  or  flapping  sound  may  be  perceived  when  the  stethoscope  is 
l^laced  over  the  larynx  or  trachea,  due  to  vibrations  in  the  current  of  air 
produced  by  the  foreign  body. 

The  diagnosis  in  cases  of  obscure  history  may  be  made  by  auscultatory 
signs,  and  by  the  fact  that  foreign  bodies  are  liable  to  show  difficulty  in 
expiration,  while  croup  and  other  obstructive  diseases  of  the  larynx  show 
more  difficulty  in  the  performance  of  inspiration.  Laryngoscopic  exami- 
nation will  often  reveal  the  presence  of  a  foreign  body  entangled  in  the 
folds  of  the  mucous  membrane  lining  the  interior  of  the  larynx. 

Treatment.— It  is  not  usual  for  foreign  substances  within  the  respi- 
ratory tract  to  be  spontaneously  expelled.  They  may  remain  for  many 
months,  and  cause,  as  a  secondary  result,  hemorrhage,  ulceration,  abscess, 
chronic  disease  of  the  lungs,  and  fatal  exhaustion.  The  danger  of  fatal 
spasm  of  the  glottis  occurring  suddenly  renders  it  important  that  the 
trachea  should  be  opened,  as  a  precautionary  measure,  as  soon  as  it  is 
determined  that  a  foreign  body  is  lodged  therein.  The  habit  indulged  in 
by  some  of  inverting  the  patient  and  slapping  him  upon  the  back  in  order 
that  the  offending  substance  may  be  expelled  is  dangerous,  and  should 


536  RESPIRATORY    ORGANS, 

never  be  attempted  until  after  the  trachea  has  been  opened,  since  impac- 
tion of  the  body  upon  the  lower  surface  of  the  glottis  may  cause  imme- 
diate asphyxia.  Anything  impacted  in  the  larynx  may  possibly  be 
removed  by  the  laryngeal  forceps  with  the  aid  of  a  laryngoscope.  In 
such  instances,  of  course,  tracheotomy  is  not  required,  although  the  sur- 
ffenn  should  be  jn-epared  to  plunge  his  knife  into  the  crico-thyroid  space, 
and  admit  air  to  the  suffocating  j)atient,  in  case  his  manipulations  cause 
spasm  of  the  glottis. 

Where  extraction  through  the  larynx  and  mouth  is  impossible,  the 
thyroid  cartilage  sliould  be  laid  o])eu  by  a  median  incision,  and  carried 
upward  after  a  puncture  has  been  made  in  the  cricothyroid  membrane. 
The  offending  body  should  then  be  removed  with  the  least  possible  lacer- 
ation of  the  mucous  membrane.  A  tube  should  be  left  in  the  wound  for 
a  day  or  two  until  all  danger  of  inflammatory  swelling  within  the  larynx 
has  j)assed.  When  the  body  lies  in  the  trachea  or  bronchus,  tracheotomy 
should  be  performed  instead  of  laryngotomy,  subsequent  to  which  the 
mucus  in  the  tube  should  be  coughed  up  by  the  patient,  or  sucked  out  by 
a  syringe  or  aspirator  in  the  hands  of  a  surgeon.  The  patient  should  then 
be  inverted  and  permitted  to  cough  in  the  hope  that  the  foreign  body  may 
be  expelled. 

Search  for  the  latter  may  be  undertaken  by  means  of  the  forceps  intro- 
duced carefully  through  the  wound.  If  it  is  not  found  the  sides  of  the 
wound  should  be  stitched  to  the  skin,  in  order  that  extrusion  may  be  per- 
mitted by  subsequent  effort  at  coughing.  The  patient  should  be  kept  in 
a  room  whose  temperature  is  not  less  than  80°  F.,  and  the  air  of  which  is 
kept  moist  by  a  steam  atomizer  or  similar  device.  The  foreign  substance 
may  be  so  fastened  in  the  trachea  or  bronchus  that  its  expulsion  may  not 
take  place  until  several  days  have  elapsed  ;  at  which  time  it  is  not  impos- 
sible that  masses  of  exudate,  similar  to  that  found  in  croup  and  diphtheria, 
may  also  be  expelled.  When  the  foreign  body  has  made  its  exit,  it  is 
wise  to  leave  the  wound  open  for  a  few  days  lest  inflammatory  swelling 
should  impede  respiration.  This  is  scarcely  necessary,  however,  except  in 
those  cases  in  which  the  foreign  body  has  become  impacted  in  the  larynx, 
because  a  considerable  amount  of  swelling  may  take  place  in  the  trachea 
without  obstructing  respiration.  In  rare  cases  a  body  lodged  in  the  larynx 
may  be  removed  better  by  opening  the  pharynx  between  the  hyoid  bone 
and  the  top  of  the  larynx. 


Tumors  of  the  Larynx  and  Trachea. 

Tumors  of  the  trachea,  as  primary  growths,  are  exceedingly  rare ;  but 
in  the  larynx  various  primary  tumors  occur,  and  are  sometimes  called 
laryngeal  polypi.  Laryngeal  tumors  cause  symptoms  similar  to  those 
induced  by  the  presence  of  foreign  bodies  in  the  larynx.  The  forms 
most  commonly  found  are  papilloma,  epithelioma,  fibroma,  adenoma,  and 
myxoma.  These  may  be  pedunculated  or  sessile,  and,  if  malignant,  ulti- 
mately involve  the  lymphatic  glands  and  other  structures  of  the  neck. 

Tuberculosis  of  the  larynx  occurs,  and  at  times  resembles  epitheliom- 
atous  disease.  Laryngeal  tumors  grow  slowly  and  attain  consideral)le 
bulk,  for  the  location,  before  marked  symptoms  occur.  Their  presence  is 
to  be  detected  by  the  laryngoscope  ;  and,  if  small,  they  may  be  removed  by 
the  forceps,  snare,  cautery,  or  laryngeal  guillotine.  In  cases  where  there 
is  great  tendency  to  spasmodic  dyspnoea,  due  to  irritation  from  the  intra- 


TUMORS    OF    THE    LARTNX    AND    TRACHEA, 


537 


Fig. 


laryngeal  condition,  precautionary  tracheotomy  may  be  required,  as  when 
foreign  bodies  are  imj^acted  in  the  glottis. 

When  a  tumor  located  within  the  larynx  cannot  be  removed  through 
the  mouth,  in  the  manner  described,  it  becomes  necessary  to  do  the  opera- 
tion called  thyrotomy. 

Thyrotomy,  or  splitting  the  thyroid  cartilage,  in  the  middle  line,  is 
accomplished  by  incision  of  the  skin  over  the  larynx,  by  which  the  thy- 
roid cartilage  and  crico-thyroid  membi*ane 
are  exposed.  The  crico-thyroid  space  is  then 
opened  with  a  knife,  and  the  incision  carried 
upward  through  the  thyroid  cartilage  almost 
to  its  upper  margin.  It  is  important  not  to 
split  the  entire  cartilage  into  its  two  halves, 
but  to  leave  a  portion  of  it  at  its  upper  border 
intact,  in  order  that  the  lateral  halves  may 
retain  their  relative  position  after  the  tumor 
has  been  removed  and  the  sutures  applied. 
During  this  operation  the  head  of  the  patient 
should  be  thrown  well  back,  in  order  to  make 
the  laryngeal  region  prominent.  When  the 
larynx  has  thus  been  opened  by  external 
incision,  its  interior  may  be  examined,  and 
any  growth  removed  by  means  of  forceps 
and  scissors.  The  cartilaginous  tissues  are 
then  sewed  together  with  fine  catgut,  and  the 
external  parts  sutured  and  dressed  in  the 
ordinary  manner.  A  solution  of  cocaine 
should  be  used  to  prevent  pain  during  the 
removal  of  such  growths  through  the  mouth  ; 
and  it  may  even  give  sufficient  anaesthesia 
for  the  operation  of  thyrotomy,  if  it  is  in- 
jected under  the  skin  about  the  line  of  the 
proposed  incision. 

A  pharyngotomy  between  the  hyoid  bone 
and  the  larynx  may,  at  times,  afford  a  good  route  for  the  extirpation  of 
laryngeal  tumors. 

Epithelioma  of  the  larynx  requires  removal  of  the  larynx,  called 
laryngectomy,  which  should  be  done  in  all  cases,  where  the  diagnosis  is 
clear,  at  an  early  stage  of  the  disease.  The  larynx  is  removed  by  means 
of  an  incision  in  the  middle  line  of  the  neck  from  the  hyoid  bone  to  the 
third  ring  of  the  trachea.  The  thyroid  body  should  be  drawn  downward 
away  from  the  field  of  operation.  The  trachea  is  then  separated  from  the 
surrounding  structures,  and  divided  transversely  at  the  level  of  the  second 
ring.  The  low^er  portion  of  the  windpipe  is  next  plugged  with  a  tampon 
of  gauze  or  sponge,  through  the  middle  of  which  passes  a  large  tube  by 
which  the  air  and  ether  vapor  are  admitted  to  the  lungs.  This  plugging 
prevents  the  blood  flowing  from  the  seat  of  operation  into  the  air-passages. 
The  larynx  must  now  be  freed  from  the  tissues  on  either  side,  separated 
from  the  hyoid  bone  above  and  the  pharynx  behind,  and  thus  totally 
removed.  The  enucleation  being  thus  completed,  the  radical  extirpa- 
tion of  the  epitheliomatous  tissue  is  accomplished. 

After  the  superior  laryngeal  arteries  and  other  vessels  have  been  tied, 
the  dressing,  consisting  of  antiseptic  gauze,  is  packed  into  the  cavity  left 
by  the  removal  of  the  larynx.     Subsequent  to  the  operation  the  patient 


Papilloma  of  larynx. 
(Treves.) 


538  RESPIRATORY    ORGANS. 

is  nourished  by  enemata  or  through  an  oesophageal  tube  until  the  wound 
ha«  cicatrized,  while  respiration  is  carried  on  through  the  lower  portion 
of  the  trachea.  After  cicatrization  has  been  accomplished,  an  artificial 
larvnx  can  be  adopted  and  the  patient  given  a  certain  amount  of  speech. 


Tkacheotomy. 

Tracheotomy,  or  opening  of  the  windpipe,  may  be  required  to  prevent 
suffocation  in  cases  of  obstruction  in  the  larynx.  Such  obstruction  occurs 
in  the  membranous  inflammation  which  takes  place  in  croup  or  diph- 
theria, in  the  occluding  swelling  of  tubercular  and  syphilitic  laryngitis, 
and  in  the  spasm  of  the  glottis  which  arises  from  foreign  bodies  or  tumors 
in  the  air-passages.  Cicatricial  narrowing  of  the  larynx  may  remain  after 
the  cure  of  syphilitic  ulcers,  and  may  cause  obstruction  demanding  trache- 
otomy. When  there  is  danger  of  asphyxia,  it  is  wisdom  on  the  part  of 
the  surgeon  to  open  the  windpipe  before  the  patient's  strength  has  been 
exhausted  by  dyspno?a.  The  operation,  if  properly  done,  is  not  at  all 
a  serious  one,  provided  it  is  performed  at  a  time  when  the  symptoms 
do  not  require  ha-^te.  Many  of  the  accidents  which  accom|)any  the 
performance  of  tracheotomy  are  due  to  its  postponement  until  the  patient 
is  moribund  ;  hence  arise  many  of  the  complications  to  what  is  other- 
wise a  comparatively  simple  operation. 

When  the  surgeon  divides  two  or  three  rings  of  the  trachea,  the  opera- 
tion is  called  tracheotomy ;  when  he  divides  the  crico-thyroid  cartilage 
and  the  crico-thyroid  membrane,  or  only  one  of  these  structures,  the 
operation  is  termed  laryngotomy.  If  the  lower  portion  of  the  larynx 
and  the  upper  part  of  the  trachea  are  opened,  the  operation  is  called 
laryngo-tracheotomy. 

Etherization  may  be  dispensed  with  in  many  cases,  since  the  painful 
part  of  the  operation  is  in  the  cutaneous  incision,  which  may  be  ren- 
dered painless  by  hypodermic  injections  of  cocaine.  The  sense  of  pain 
is  practically  absent,  moreover,  in  conditions  of  imminent  suffocation 
from  prolonged  laryngeal  obstruction.  I  myself,  however,  nearly  always 
prefer  general  anaesthesia,  especially  in  infancy,  since  movement  of  the 
cliild,  even  if  it  suffers  but  little  pain,  interferes  with  the  operation. 
When  the  trachea  is  to  be  opened,  the  patient's  shoulders  should  be 
raised  by  thrusting  a  pillow  under  them,  and  the  head  thrown  back  so 
as  to  put  the  neck  on  the  sti-etch.  A  median  incision  is  then  carried 
from  the  crico-thyroid  space  ahnost  to  the  sternum.  Its  length  depends 
upon  the  thickness  of  the  neck  and  the  consequent  depth  at  which  the 
trachea  is  situated.  The  veins,  swollen  because  of  interference  with 
respiration  on  account  of  the  patient  being  in  a  state  of  asphyxia  at 
the  time  of  operation,  .should  be  avoided  if  it  is  practical.  Their 
division,  however,  is  not  a  matter  of  serious  moment,  since  they  stop 
bleeding  as  soon  as  respiration  is  reestablished.  The  dissection  is  con- 
tinued in  the  middle  line,  through  the  deep  fascia  and  between  the 
sterno-hyoid  muscles,  until  the  thyroid  gland  is  exposed.  The  isthmus 
of  this  body  should  be  pushed  downward,  or  drawn  upward,  according 
as  the  surgeon  intends  to  open  the  trachea  at  the  lowest  accessible 
point  or  in  a  higher  position.  When  the  isthmus,  on  account  of  its 
size,  cannot  be  displaced,  a  ligature  should  be  tied  around  it  on  each 
side  in  order  to  prevent  hemorrhage,  and  midway  between  these  liga- 
tures   it   should    be   divided.      The  windpipe  can  be  recognized  by  its 


TRACHEOTOMY. 


539 


white  color.  A  tenaculum  is  hooked  into  the  tracheal  wall  to  steady 
it,  a  sharp-pointed  knife  then  thrust  into  the  Avindpipe,  and  two  or 
three  rings  divided  in  an  upward  direction.  The  incision  must,  of  course, 
correspond  with  the  median  cutaneous  incision,  in  order  that  the  open- 
ing in  the  Avindpipe  may  not  be  closed  by  the  overlying  tissue  covering 
it  after  the  surgeon  has  permitted  the  trachea  to  slip  from  the  tenacu- 
lum. It  is  very  important  that  no  blood  should  get  into  the  trachea  by 
the  first  inspiratory  effort  after  the  opening  is  made,  and  from  thence  be 
carried  into  the  bronchi.  Such  inhalation  of  blood  may  suffocate  the 
patient.  In  some  cases  it  may  be  impossible  to  stop  all  bleeding  before 
the  tracheal  cut  is  made ;  therefore,  the  patient  should  be  turned  upon 
his  face  with  his  head  over  the  edge  of  the  table,  and  retained  in  this 
position  while  the  opening  is  made.  The  blood  will  then  fl^ow  out  of, 
instead  of  settling  in  the  bottom  of,  the  wound.  The  danger  of  its 
being  sucked  into  the  air-passages  will  thus  be  averted.  As  soon  as 
the  rings  have  been  divided,  it  is  well  to  thrust  a  pair  of  forceps  into 
the  trachea  in  order  to  hold  the  lips 

of  the  wound  apart.    In  this  manner  yig  35s. 

a  supply  of  air  is  at  once  given  to 
the  patient,  and  the  false  membrane 
or  mucus  which  has  obstructed  the 
respiratory  passage,  can  be  removed. 
It  may  be  necessary  to  wipe  out  such 
obstructing  material  with  a  feather 
or  camel's -hair  pencil  passed  into 
the  windpipe,  or  to  suck  it  out  by 
means  of  a  catheter  to  which  an 
aspirator  or  a  syringe  has  been  at- 
tached. In  diphtheritic  cases  it  is 
dangerous  and  foolish  for  the  surgeon  to  suck  out  such  membrane  with 
his  mouth,  since  fatal  consequences  to  the  operator  have  often  followed 
this  practice.  After  the  trachea  has  been  cleared,  a  tracheal  tube  may 
be  inserted  in  order  that  the  respiration  may  go  on  without  obstruction 
from  falling  together  of  the  lips  of  the  wound.  A  tracheal  tube  consists 
of  a  double  canula,  the  inner  one  of  which  projects  at  the  internal  end  a 
little  beyond  the  outer  one.  The  object  in  having  two  tubes  is  to  enable 
the  attendant  to  remove  and  clean  the  inner  tube,  as  it  becomes  plugged 
with  mucus  or  dried  seci-etions,  while  he  leaves  the  outer  one  in  the  wound 
in  order  to  make  replacement  of  the  inner  tube  easy. 

The  outer  tube  has  flanges  upon  each  side,  by  which  it  is  held  in  place 
by  means  of  tapes  and  tied  around  the  neck.     I  prefer,  however,  to  fix 
these  wings  or  flanges  by  means  of  sutures  carried  through  the  neighboring 
skin  with  a  needle.     The  upper  and  lower  angles  of 
the  cutaneous  wound  may  be  sutured  after  the  tube 
has  been  inserted.   There  are  several  forms  of  tracheal 
dilators  made  which  are  preferred  by  some  operators 
to  the  canula. 

In  diphtheritic  patients  less  skilled  nursing  is  re- 
quired if,  instead  of  introducing  the  canula,  the  sur- 
geon cuts  out  a  small  rectangular  portion  of  the 
trachea  and  stitches  the  edges  of  the  tracheal  opening 
to  the  skin.  The  tube  requires  constant  watching, 
and  must  be  kept  free  from  obstruction  by  dried  membrane,  secretion,  or 
blood,  by  the  frequent  passing  of  a  feather  through  it.      In  diphtheritic 


Trachea  tube,  with  valve. 


Fig.  359. 


Tracheal  dilator. 


540  RESPIRATORY    ORGANS. 

cases  the  inner  tube  should  be  removed  and  cleaned  about  every  two 
hours,  and  both  tubes  should  l)e  removed  if  there  are  any  evidences  of 
serious  obstruction. 

The  patient,  wliose  windpipe  has  thus  been  opened,  cannot  talk  unless 
the  orifice  in  the  throat  is  closed  by  placing  a  finger  over  the  tube,  or  in 
some  wav  preventing  respiration  through  the  anterior  orifice.  In  four  or 
five  days  afler  tlie  operation  for  diphtheria  it  is  ))roper  to  make  an  attempt 
to  dispense  with  the  tube;  but  if  symptoms  of  laryngeal  obstruction  still 
remain,  the  tube  must  be  reinsei-ted  for  a  few  days  longer.  It  is  essential 
that  the  patient  upon  whom  tracheotomy  has  been  done  should  be  kept 
in  a  hot  room  with  a  moist  atmosphere  until  the  symptoms  for  which  the 
operation  was  done  have  subsided,  since  bronchitis  or  pneumonia  are  very 
liable  to  occur  from  inspiration  of  cold,  dry  air.  Inhalation  of  dust  should 
be  prevented,  if  possible,  by  keeping  a  piece  of  mo.squito-netting  in  front 
of  the  opening  in  the  thro.-'.t.  This,  however,  is  often  impossible  in  opera- 
tions for  diphtheria  where  there  is  frequent  necessity  for  cleansing  the 
tube.  The  temperature  of  the  room  should  be  kept  at  75°  or  80°  F.,  and 
the  air  should  be  kept  moist  by  means  of  an  atomizer,  or  by  a  wet  blanket 
suspended  in  the  room  before  a  fire.  The  interior  of  the  trachea  and  the 
wound  may  be  mopped  with  a  solution  of  sodium  carbonate  in  glycerin, 
or  with  a  solution  of  pepsin  or  of  trypsin,  in  order  to  facilitate  detach- 
ment of  the  false  diphtheritic  membrane.  It  has  been  suggested  that, 
after  tracheotomy  for  diphtheria,  the  windpipe  above  the  seat  of  operation 
may  with  benefit  be  plugged  with  sublimate  gauze  (1:  2000). 

A  quick  tracheotomy  may  be  done  in  emergency  cases  by  grasping  the 
larynx  between  the  thumb  and  forefinger  of  the  left  hand  and  steadying 
it  in  this  manner,  while  a  rapid  incision  is  made  with  the  right  hand  in 
the  middle  line.  In  still  greater  emergency  air  may  be  admitted  to  the 
lungs  by  plunging  a  knife  through  the  crico-thyroid  space,  which  is  easily 
felt  as  a  depression  about  three-quarters  of  an  inch  below  the  most 
prominent  point  of  the  Adam's  apple.  An  opening  thus  made  will 
permit  air  to  enter  in  sufficient  quantity  until  a  more  .systematic  operation 
can  be  done.  I  have  operated  in  this  manner  by  means  of  an  ordinary 
pocket-knife,  which  is  usually  always  obtainable.  Where  it  is  impossible 
to  obtain  a  proper  tracheal  tube,  a  piece  of  a  drainage-tube  will  tem- 
porarily answer  the  purpose.  If  the  patient  has  stopped  breathing  by  the 
time  the  surgeon  has  gained  an  entrance  to  the  windpipe,  artificial  respira- 
tion can  possibly  be  started  by  blowing  into  the  tube  with  an  ordinary 
.syringe  or  a  pair  of  bellows.  It  is  wise  always  to  introduce  the  largest 
size  canula  that  the  trachea  will  hold.  It  must  not  be  so  large,  however, 
as  to  strip  up  the  mucous  membrane  as  it  is  pushed  down  into  the  wind- 
pipe. A  slight  alteration  as  to  its  length  or  shape,  and  also  its  removal 
from  time  to  time,  are  desirable,  because  the  i)ressure  exerted  by  its  internal 
end  may  induce  ulceration  of  the  lining  membrane  of  the  windpipe.  The 
lobster-tail  canula,  with  a  bluut  pilot  for  its  introduction,  is  a  favorite  one 
with  me. 

In  cases  of  stenosis  of  the  larynx  in  which  the  tracheal  tube  must  be 
constantly  worn,  a  tube  with  an  opening  in  the  intratracheal  portion  will 
enable  the  patient  to  expire  through  the  larynx  and  to  talk  with  com- 
parative ease.  If  the  tube  has  not  this  opening,  and  it  fits  tightly  so  that 
no  air  passes  above  the  opening,  speech  is  impossible. 

The  point  at  which  an  opening  in  the  air-passages  should  be  made 
depends  upon  the  condition  for  which  the  operation  is  done.  In  diphtheria 
it  is  best  to  go  as  low  down  as  possible  ;  hence,  a  point  below  the  isthmus 


TRACHEOTOMY. 


541 


of  tlie  thyroid  gland  is  probably  the  best  place  under  such  circumstances. 
In  tracheotomy  for  chronic  disease  of  the  larynx,  a  high  tracheotomy 
above  the  thyroid  body  is  efficacious  and  makes  a  less  difficult  operation. 


Double  tracheal  tube  (lobster  tail). 


Intubation  of  the  Larynx. 

The  introduction  of  a  metal  tube  into  the  chink  of  the  glottis  and  its 
retention  there  for  a  period  varying  from  several  hours  to  several  days,  is 
called  intubation,  and  is  in  certain  cases  a  good  substitute  for  the  more 
serious  operation  of  tracheotomy.  Though  especially  employed  in  cases 
of  diphtheria  and  oedema  of  the  glottis,  it  is  jDossible  that  it  may  be  of 
advantage  in  cases  of  foreign  bodies  in  the  trachea,  because  it  will  prob- 
ably prevent  fatal  asphyxia  from  spasm  of  the  glottis,  due  to  such  foreign 
body  being  coughed  up  against  the  lower  surface  of  the  vocal  chords.  In 
such  a  condition  intubation  would  seem  to  be  of  service  as  a  temporary 
measure  until  arrangements  can  be  made  to  open  the  trachea  for  extraction 
of  the  foreign  substance. 

Intubation,  which  is  seldom  required  in  adults,  is  performed  with  the 
child  held  in  the  nurse's  arms  without  being  etherized.  A  gag  is  placed 
between  the  teeth  on  the  left  side  of  the  mouth  in  order  to  hold  the  jaws 
apart,  and  an  assistant  holds  the  patient's  head  well  back.  The  surgeon 
introduces  his  left  forefinger  into  the  mouth  and  by  pressing  down  the 
tongue  he  is  enabled  to  guide  the  tube  with  his  right  hand  into  the  glottis. 
After  it  has  been  so  introduced  the  detachable  handle  or  obturator  is  re- 
moved. The  patient  then  breathes  through  the  tube,  which  is  kept  in 
place  by  reason  of  its  shape.  At  the  top  of  the  tube  is  a  flange  to  pre- 
vent the  instrument  slipping  into  the  trachea,  and  in  this  flange  is  a  small 
hole  through  which  a  long  thread  is  passed  before  any  attempt  at  intro- 


542  RESPIRATORY    ORGANS. 

duction  is  made.  The  ends  of  this  thread  hang  from  the  mouth  and  are 
used  to  remove  the  instrument  from  the  pliarynx  if  it  is  found  not  to  be 
jjroperly  placed  when  tlie  <letachable  handle  is  withdrawn.  If,  however, 
the  surgeon  finds  the  patient  breathing  well  and  the  tube  properly  placed 
the  string  is  withdrawn  and  the  instrument  left  in  position.  If  all  goes 
well  the  tube  may  be  left  in  position  for  several  days.  When  its  extrac- 
tion is  desired  an  instrument  called  by  Dr.  O'Dwyer  the  extractor  is 
introduced.  This  instrument  is  operated  by  expanding  two  blades  or  jaws 
after  its  point  is  introduced  into  the  calibre  of  the  tube  thereby  giving 
the  surgeon  control  of  the  latter  and  enabling  him  to  withdraw  it  quickly. 
During  the  introduction  and  withdiawal  of  the  laryngeal  tube  respiration 
is  entirely  arrested  for  u  moment. 

An  advantage  of  intubation  is  that  the  consent  of  the  patient's  family 
can  be  more  readily  obtained  for  the  })erformance  of  the  operation  than 
is  the  case  in  tracheotomy,  which  causes  bleeding,  and  therefore  seems  to 
them  more  undesirable  and  dangerous. 

The  objections  to  intubation  are  that  the  tube  may  slip  into  the  trachea, 
that  it  may  be  swallowed,  and  that  food  gets  into  the  air-passages,  thus 
causing  at  times  secondary  pneumonia.  It  has  been  supposed  by  some 
that  there  is  danger  that  the  false  membrane  of  diphtheria  maybe  pushed 
down  into  the  trachea  by  means  of  the  tube,  thereby  incretising  the  res- 
])iratory  obstruction.  This  objection,  however,  applies  equally  to  the 
inserticm  of  a  tube  after  tracheotomy.  Intubation,  moreover,  does  not 
prevent  tracheotomy  being  performed  later,  if  the  necessity  for  it  arises. 
Attempts  have  been  made  to  correct  the  difficulty  of  feeding  after  intu- 
bation, by  attaching  a  sort  of  artificial  epiglottis  to  the  upper  end  of  the 
tube. 

Intubation  is  a  valuable  addition  to  the  surgeon's  resources,  for  which 
the  profession  owes  much  to  Dr.  O'Dwyer;  but  is  often  inferior  to  the 
more  radical  operation,  tracheotomy. 

Diseases  of  the  Chest. 

Concisions  and  Abscesses. 

Pathology  and  Symptoms. — Contusions  and  abscesses  of  the  chest 
wall  require  no  special  description  other  than  to  say  that  abscess  of  the 
chest  wall  is  occasionally  secondary  to  purulent  effusion  in  the  pleural 
cavity  or  to  abscess  of  the  lung. 

Contusion  or  rupture  of  the  lung  tissue  may  occur  without  laceration 
of  the  pleura.  These  l&sions  probably  take  place  because  the  lung  is  sub- 
jected to  blows  or  concussions  when  the  vesicles  are  filled  with  air  and 
the  glottis  closed,  so  that  the  air  within  the  lung  tissue  cannot  be  forced 
out  at  the  time  the  force  is  applied.  The  symptoms  of  this  condition  are 
spitting  of  blood,  diaphragmatic  breathing,  dyspnoea,  cough,  bronchial 
rales,  and  signs  of  localized  pneumonia,  or  pleurisy.  These  symptoms 
vary  with  the  extent  and  location  of  the  injury.  Emphysema  may  occur 
between  the  lung  and  the  pulmonary  pleura,  and  the  air  so  extravasated 
may  find  its  way  into  the  mediastinum  and  upward  into  the  cellular 
tissue  of  the  neck  and  back.  If  the  pluera  is  torn  by  the  injury,  blood 
and  air  may  escape  into  the  pleural  cavity  and  produce  h^emo-thorax  or 
pneumo-thorax  with  their  characteristic  physical  signs. 

Pulmonary  al)scess,  or  gangrene,  and  mediastinal  abscess  are  occasional 


DISEASES    OF    THE    CHEST.  543 

sequences  of  luug  injuries.  Gunshot  and  stab  wounds  of  the  lung  are 
not  infrequent ;  and  laceration  of  the  periphery  of  the  lung  may  happen 
as  a  complication  of  fracture  of  the  ribs.  Laceration  may  occur  from 
puncture  of  the  lung  by  one  of  the  fragments  at  the  time  the  fracture  of 
the  rib  is  received,  though  subsequently  no  displacement  of  bone  may  be 
discoverable,  because  the  resiliency  of  the  chest  -svall  has  brought  the 
fragments  of  bone  into  apposition. 

The  symptoms  of  such  wounds  of  the  pulmonary  tissue  are  similar  to 
those  described  above  as  occurring  from  contusion  and  rupture  of  the 
lung.  Subcutaneous  emphysema  is  a  very  common  concomitant  of  frac- 
ture of  the  ribs  when  one  of  the  fragments  has  injured  the  lung.  In 
such  instances  the  air  in  the  vesicles  escapes  into  the  pleural  cavity,  and 
then  during  expiration  is  pumped  through  the  opening  in  the  costal 
pleura  into  the  subcutaneous  cellular  tissue. 

It  must  be  remembered  that  the  lung  extends  downward  at  the  lateral 
and  posterior  aspects  of  the  chest  to  about  the  level  of  the  tenth  rib, 
while  the  pleural  cavity  extends  as  far  downward  as  the  twelfth  rib.  In 
a  wound  of  the  chest  below  the  tenth  rib,  therefore,  the  pleura  alone  will 
probably  be  wounded,  and  not  the  lung.  If  a  penetrating  wound  extends 
sufficiently  deep  to  traverse  the  pleural  sac,  puncture  the  diaphragm, 
and  enter  the  abdominal  cavity,  the  organs  contained  in  the  abdomen 
may  suffer  injury  from  the  bullet  or  knife  in  addition  to  the  damage  sus- 
tained by  the  pleura.  The  arching  upward  of  the  diaphragm  renders  it 
possible  for  a  penetrating  injury,  even  higher  than  the  tenth  rib,  to  pro- 
duce lesions  of  both  the  thoracic  and  abdominal  viscera.  When  the 
wound  of  the  chest  wall  is  a  comparatively  large  one,  its  communication 
with  the  pleural  sac  is  often  to  be  recognized  by  the  sucking  and  hissing 
sound  produced  by  the  air  entering  the  chest  during  respiration.  If  a 
large  vessel  in  the  lung  is  wounded,  the  bronchial  tubes  may  be  so  filled 
with  blood  as  actually  to  drown  the  patient. 

Pulmonary  wounds  heal  like  other  wounds  if  protected  from  suppura- 
tion and  putrefaction.  The  air  entering  the  pulmonary  tissue  through 
the  trachea  is  freed  from  pathogenic  germs  to  a  great  extent  by  the  filter- 
ing process  which  it  unclergoes  before  it  reaches  the  seat  of  the  wound  ; 
hence,  if  the  chest  wound  be  kept  aseptic,  there  is  little  danger  of  suppu- 
ration or  septic  pneumonia  or  pleurisy.  Protrusion  of  a  lung  may  occur 
at  the  cicatrix  of  a  large  wound  in  the  chest  wall. 

Treatment. — ^The  external  bleeding  in  chest  wounds  is  usually  not 
very  severe,  and  needs  no  special  treatment.  If  the  blood  comes  from 
the  lungs  it  will  probably  be  frothy  and  in  greater  quantity  during  expi- 
ration than  in  inspiration.  The  flow  of  blood  into  the  pleural  sac,  which 
occurs  at  the  same  time  or  before  escaping  from  the  chest  through  the 
external  opening,  will  probably  soon  make  sufficient  pressure  upon  the 
lung  to  stop  the  bleeding  from  the  pulmonary  tissue.  The  blood  so  enter- 
ing the  pleural  cavity  will,  if  kept  aseptic,  subsequently  be  absorbed  ;  if 
not  kept  antiseptic,  it  will  break  down  into  pus  and  cause  traumatic 
empyema. 

Severe  hemorrhage  may  supervene  from  wounds  of  the  intercostal  and 
mammary  arteries.  The  intercostal  arteries  lie  in  grooves  at  the  inner 
and  lower  margins  of  the  ribs.  Hemorrhage  from  one  of  these  vessels 
may  be  stopped  by  seizing  the  bleeding  point  with  a  hemostatic  forceps, 
which  may  be  left  in  position  for  several  hours.  If  arrest  of  hemorrhage 
by  this  means  be  impossible,  the  surgeon  may  perhaps  be  able  to  scrape 
off,  with  a  blunt  instrument,  the  periosteum  from  the  bottom  of  the  inter- 


544  RESPIRATORY    ORGANS. 

costal  (groove.  This  j)roce(lure  separates  the  vessel  from  the  bone,  and 
makes  its  ligation  practicable.  Another  method  is  to  push  into  the  wound 
tlie  centre  of  a  s(]uare  {)iecc  of  antiseptic  gauze,  and,  after  distending  it 
like  a  small  bag  witliin  the  chest,  to  stulf  the  pouch  so  made  with  small 
pieces  of  antiseptic  sponge  or  gauze.  By  seizing  the  projecting  corners 
of  the  square  of  gauze  and  drawing  the  intrathoracic  mass  firmly  against 
the  internal  surface  of  the  ribs,  pressure  is  made  upon  the  intercostal 
vessel  and  bleeding  prevented.  Resection  of  a  portion  of  the  rib  is 
seldom  necessary  to  gain  control  of  the  vessel  from  which  hemorrhage 
occurs. 

The  internal  mammary  artery  runs  parallel  to  the  border  of  the 
sternum,  and  from  a  quarter  to  half  an  inch  external  to  this  margin. 
Bleeding  from  a  wound  in  the  internal  mammary  artery  should  be  treated 
bv  ligation  or  by  seizing  the  bleeding  point  with  a  hemostatic  forceps, 
which  should  then  be  left  in  position  with  antiseptic  dressing  packed 
around  it. 

As  a  rule,  little  information  is  obtainable  by  the  introduction  of  probes 
into  a  chest  wound.  There  is  no  objection  to  their  use,  if  they  are  em- 
ployed with  caution  and  antiseptically.  When  the  wound  is  large  enough 
to  admit  the  surgeon's  finger,  which,  of  course,  must  be  aseptic,  a  clear 
understanding  of  the  nature  of  the  injury  is  often  obtained. 

The  subcutaneous  emphysema  which  is  sometimes  present  in  lung 
injuries,  is  recognized  by  the  elastic  swelling  of  the  skin,  which  crackles 
when  pressed  upon  by  the  fingers.  This  tumefiiction,  which  is  free  from 
any  discoloration  such  as  occurs  in  cutaneous  inflammations,  occurs 
during  the  first  few  hours  after  injury,  and  afterward  subsides  gradually 
without  treatment. 

Antiseptic  cleansing  of  the  wound,  the  introduction  of  sutures,  and  the 
application  of  dressings,  fulfil  the  local  requirements  of  the  thoracic 
wounds.  In  order  to  keep  the  chest  at  rest  as  much  as  possible,  a  firm 
bandage  should  then  be  applied.  If  suppuration  occurs  in  the  pleural 
cavity,  the  wound  must  be  thoroughly  opened,  a  drainage-tube  inserted, 
and  antiseptic  irrigation  carried  on  in  the  manner  discussed  under 
Pleural  Effusion.  If  the  traumatic  pneumonia  is  very  acute  and  exten- 
sive, venesection  may  be  the  only  means  to  preserve  life.  In  other  cases 
secondary  pneumonia  and  pleurisy  should  be  treated  by  ordinary  medical 
means.  The  fact  that  persons  subjected  to  accidental  wounds  of  the  chest 
are  usually  in  a  good  state  of  health,  and  that,  therefore,  the  intrathoracic 
inflammation  is  of  a  sthenic  type,  indicates  that  active  depressants  and 
purgatives  are  more  often  ncessary  than  in  cases  of  idiopathic  pneumonia 
and  pleurisy.  The  diagnosis  of  the  inflammatory  conditions  within  the 
chest  is  made,  of  course,  by  the  ordinary  rules  of  auscultation  and  per- 
cussion. 

Bullets  and  other  foreign  bodies,  unless  their  location  is  definitely  de- 
termined, and  found  to  be  accessible  to  the  knife  without  adding  much  to 
the  original  injury,  should  be  allowed  to  remain  imbedded  in  the  tissues. 
They  often  become  encysted,  and  do  no  harm.  If  subcutaneous  abscess  or 
a  sinus  indicates  their  position,  the  surgeon  is  justified  in  undertaking 
operative  search.  Under  such  circumstances  I  have  recently  successfully 
removed,  after  resection  of  the  ribs,  a  piece  of  silver  drainage-tube  from 
a  young  child's  chest,  where  it  had  been  for  many  months,  after  having 
become  lost  during  treatment  for  idiopathic  empyema. 


SURGICAL    TREATMENT    OF    PLEURAL    EFFUSIONS.      545 


Surgical  Treatment  of  Pleural  Effusions. 

Aspiration  of  the  jileural  cavity  or  thoracentesis  is  performed  in  serous 
eifasion  into  the  pleural  cavity  (hydrothorax).  Incision  of  the  chest  wall 
with  the  introduction  and  retention  of  a  drainage-tube  into  the  pleural 
sac  is  the  proper  surgical  treatment  in  cases  of  purulent  effusion  into  the 
pleural  sac  (empyema).  In  hydrothorax  aspiration  should  be  done  com- 
paratively early,  or  as  soon,  at  least,  as  medicinal  remedies  do  not  produce 
any  marked  diminution  of  the  quantity  of  fluid  in  the  cavity.  Incision 
and  drainage  should  be  performed  as  soon  as  the  existence  of  pus  is  deter- 
mined. Aspiration  should  be  done  with  a  hollow  needle,  and  one  of  the 
forms  of  aspirating  pumps.  Care  should  be  taken  that  no  air  enters  the 
chest,  and  that  the  lungs  and  other  structures  of  importance  are  not 
injured  by  the  point  of  the  needle.  If  an  aspirator  is  not  obtainable  an 
ordinary  trocar  and  canula  is  used.  A  long,  rubber  tube,  however, 
should  be  attached  during  the  first  flow  of  serum,  immediately  after  the 
trocar  has  been  withdrawn,  and  the  end  of  this  tube  placed  below  the 
surface  of  a  solution  of  carbolic  acid  (1  :  20).  This  precaution  is  taken 
to  prevent  the  sucking  up  of  air  into  the  chest  when  the  flow  of  serum 
becomes  intermittent  as  the  cavity  is  nearly  evacuated. 

Thoracentesis  does  not  require  general  anaesthesia.  If  the  patient  is 
very  sensitive  to  pain  the  skin  at  the  point  of  the  proposed  puncture  may 
be  benumbed  by  a  spray  of  ether  or  rhigolene,  by  a  hypodermic  injection 
of  cocaine,  or  by  the  application  of  ice  and  salt.  The  best  position  for 
the  patient  is  a  semi-recumbent  one,  which  can  be  changed  during  the 
operation  to  a  recumbent  one,  as  he  becomes  weak.  The  place  to  insert 
a  puncturing  instrument  is  in  the  sixth  interspace  close  above  the  upper 
border  of  the  seventh  rib  and  in  a  line  with  the  middle  of  the  axilla.  If 
careful  auscultation  and  percussion  indicate  the  presence  of  a  localized 
pleural  effusion  it  may  be  necessary  to  select  another  spot ;  since  it  is  evident 
that  a  cavity  containing  fluid  should  be  tapped  near  its  lower  wall,  as  this 
gives  the  best  opportunity  for  entire  evacuation  of  its  contents.  As  soon 
as  the  aspirating  needle  enters  the  pleural  sac  the  flow  of  serum  is  evident 
in  the  glass  tube  near  the  needle,  or  in  the  bottom  of  the  aspirator.  The 
escape  of  fluid  should  be  at  first  somewhat  controlled,  in  order  that  sud- 
den evacuation  of  the  contents  of  the  pleural  cavity  may  not  lead  to 
syncope.  It  is  also  wise  occasionally  to  stop  the  flow  for  a  moment.  The 
occurrence  of  cough  is  an  indication  to  desist  temporarily ;  while  a  dis- 
charge of  blood  through  the  needle  means  that  the  lung,  or  some  vessel, 
has  been  injured,  and  suggests  the  partial  withdrawal  of  the  instrument. 
When  the  fluid  ceases  to  escape  the  operation  is  concluded  by  drawing 
out  the  needle,  unless  it  is  believed  from  the  physical  signs  that  the  calibre 
of  the  aspirator  has  been  plugged  by  a  mass  of  lymph  sucked  into  the 
tube.  This  complication  is,  as  a  rule,  indicated  by  a  sudden,  rather  than 
a  gradual,  cessation  of  the  flow.  It  may  be  possible,  by  changing  the  cur- 
rent in  the  aspirator,  if  the  instrument  permits  such  a  procedure,  to  force 
the  lymph  back  into  the  chest.  If  this  is  impossible  it  may  be  necessary 
to  withdraw  the  needle,  remove  the  obstruction,  and  puncture  in  a  new 
place. 

An  antiseptic  pad  should  be  placed  over  the  opening  after  the  operation 
has  been  performed,  and  the  patient  treated  by  medical  means  as  previ- 
ously. 

Drainage  of  purulent  effusions  in  the  pleural  cavity  is  accomplished  by 

35 


54t)  RESPIRATORY    ORGANS. 

making  a  two-inclj  incision  in  one  of  tlie  intercostal  spaces  just  above  the 
u])j)or  border  of  one  of  the  ribs  and  parallel  to  the  rib.  This  site  is 
chosen  for  aspiration  and  incision,  because  the  intercostal  artery  rung 
along  the  lower  edge  of  each  rib.  If  there  is  any  doubt  about  the  possi- 
bility of  the  space  between  the  ribs  being  .-sufficiently  large  for  the  sur- 
geon's purpose,  the  initial  incision  had,  perhaps,  better  be  made  in  the 
middle  of  the  intercostal  space,  rather  than  clo.se  to  the  upper  border  of 
the  lower  rib.  The  sixth  interspace  is,  as  a  rule,  a  good  place  for  incising 
the  pleura.  If  there  is  anv  evidence  of  the  pus  collection  being  localized 
the  surgeon  would  naturally  make  his  incision  a  little  below  the  centre  of 
the  area  of  dulness.  As  the  patient  after  such  an  operation  lie.s  upon  his 
back,  the  incision  should  be  made  about  an  inch  behind  a  line  downward 
from  the  middle  of  the  axilla.  The  cutaneous  incision  should  be  suffi- 
ciently large  to  permit  a  good  size  tube  to  be  introduced.  If  the  space 
between  the  ribs  is  not  sufficient  a  portion  of  the  lower  rib  should  be 
excised.  It  is  not  often  necessary  to  remove  a  section  of  the  entire  width 
of  the  rib,  as  a  semicircle  cut  out  of  the  bone  with  bone  forceps  or  saw 
will  usually  give  sufficient  space  for  the  tube.  My  own  experience  has 
shown  that  excision  of  the  rib  for  this  purpose  is  seldom  required.  If, 
however,  it  seems  necessary  to  remove  a  section  of  the  entire  width  of  the 
rib  the  operation  should  begin  by  an  incision  over  the  middle  of  the  rib ; 
after  which  the  periosteum  should  be  detached  and  about  an  inch  of  the 
rib  sawed  out.  The  intercostal  artery  in  such  an  operation  should  be 
secured  before  the  pleura  is  opened. 

After  the  dissection  has  been  carried  down  to  the  pleura  and  hemor- 
rhage stopped,  if  there  be  any,  the  pleura  should  be  laid  open  to  the  full 
extent  of  the  external  wound.  The  surgeon's  finger  can  then  be  inserted, 
the  interior  of  the  chest  explored,  and  any  bands  of  lymph  that  divide 
the  pleura  into  separate  cavities  broken  up.  Etherization  is  not  e.spential 
in  this  procedure,  as  the  pain  is  not  very  much  greater  than  that  of  aspi- 
ration. Local  aiuesthesia  is  sufficient.  A  rubber  drainage-tube  without 
side  holes  and  with  a  calibre  of  about  one-quarter  of  an  inch  should  be 
introduced  about  an  inch  into  the  pleural  cavity  and  stitched  to  the  skin 
by  wire  or  silk  sutures.  After  the  extremities  of  the  wound  have  been 
drawn  together  with  sutures,  a  voluminous  antiseptic  dressing  should  then 
be  applied.  The  pleural  cavity  should  be  washed  out  with  a  solution  of 
carbolic  acid  (1 :  40),  betanaphthol  (1  :  4000),  salicylic  acid  or  boric  acid 
once  in  twenty-four  houre.  These  disinfectant  solutions  are  introduced 
by  hydrostatic  pressure,  obtained  by  attaching  to  the  drainage-tube  an- 
other tube  or  pipe  coming  from  a  reservoir  held  about  two  feet  above  the 
patient.  As  soon  as  distention  of  the  cavity  by  the  fiuid  produces  pain 
the  supply-tube  should  be  detached,  or  the  reservoir  lowered  so  that  the 
mingled  i)us  and  antiseptic  solution  may  escape.  One  or  two  pints  of 
fiuid  may  be  introduced  into  the  chest  at  one  injection,  and  it  may  be 
repeated  until  the  outflow  is  very  little  stained  with  pus.  Irrigation  and 
drainage  in  this  manner  should  be  continued  for  several  weeks,  and 
should  not  be  discontinued  until  it  is  evident  that  the  cavity  within  the 
chest  has  greatly  contracted,  and  there  is  very  little  purulent  collection. 
When  this  occurs  the  drainage-tube  may  be  withdrawn  and  the  wound 
allowed  to  heal  by  granulation.  Too  early  withdrawal  of  the  tube  may 
permit  re-accumulation  of  the  pus,  and  necessitate  a  second  operation,  in 
order  to  relieve  the  septic  symptoms  which  are  liable  to  occur.  If  the 
fistulous  opening,  left  after  the  drainage-tube  is  withdrawn,  remains  for 
many  months,  further  treatment  will  be  required.     The  condition  is,  in 


DISEASES    OF    THE    NECK.  547 

rare  instances,  due  to  a  broken  portion  of  the  tube  having  been  left 
within  the  chest ;  but  is  more  apt  to  happen  because  the  drainage  has  not 
been  complete,  or  because  the  tube  has  been  withdraAvn  too  eai-ly.  Dila- 
tation of  the  fistulous  track  by  the  introduction  of  a  sponge  tent,  or  a 
piece  of  compressed  spcnge,  will  often  permit  reestablishment  of  irrigation 
and  thereby  induce  cure.  In  other  cases  it  may  be  necessary  to  lay  open 
the  sinus  and  resect  a  portion  of  a  rib  in  order  to  obtain  free  drainage. 
In  some  cases  healing  of  the  pleural  cavity  is  prevented  by  the  fact  that 
the  pus  sac  will  not  collapse  because  of  inflammatory  thickening  and 
adhesions.  Under  such  circumstances  it  has  been  advocated  that  two  or 
three  inches  of  several  contiguous  ribs  be  excised  in  order  that  the 
chest  wall  becoming  flaccid  may  fall  inward,  and  by  coming  in  contact 
with  the  pulmonary  wall  of  the  pus  sac  cause  the  cavity  to  become  oblit- 
erated. In  performing  this  operation  it  is  well  to  dissect  away  the  thick- 
ened costal  pleura. 

Pulmonary  Abscess  and  Gangrene. 

The  operative  treatment  of  pulmonary  abscess  consists  in  cutting  into 
the  lung,  after  having  incised  the  chest  wall  and  pleura,  in  order  to  evac- 
uate the  pus  confined  in  the  lung  tissue.  Before  such  an  operation  is 
attempted  the  most  careful  physical  diagnosis  must  locate  the  abscess,  and 
even  then  it  is  wise  to  confirm  the  physical  signs  by  introducing  an  aspi- 
rating needle  or  trocar  into  the  lung.  When  such  abscess  has  been  dis- 
covered incision  of  the  external  tissues  and  lung  is  proper,  and  should  be 
followed  by  the  insertion  of  a  large  drainage-tube  so  that  irrigation  may 
be  carried  on.  Excision  of  a  gangrenous  portion  of  the  lung  has  been 
attempted  after  opening  the  chest.  The  difficulties  in  diagnosing  the  po- 
sition of  the  gangrenous  area  are  similar  to  those  met  in  diagnosing  the 
position  of  an  abscess. 

Mediastinal  Tumors  and  Abscesses. 

Pus  in  the  anterior  mediastinum  may  be  evacuated  by  an  incision 
between  the  costal  cartilages,  or  by  trephining  the  sternum.  Such  a  pos- 
sible condition  should  be  given  consideration  when  the  surgeon  is  investi- 
gating any  obscure  case  of  thoracic  disease.  Tumors  of  the  mediastinum 
should  also  be  remembered  in  this  connection. 


Diseases  of  the  K'eck. 

Wounds  of  the  neck  should  be  treated  as  other  wounds.  If  the  trachea 
or  glottis  is  opened  the  parts  should  be  brought  together  and  sutured  and 
provision  made  for  drainage.  Severe  wounds  of  these  structures  are 
often  made  in  suicidal  attempts.  After  the  parts  have  been  sutured  an 
oesophageal  tube  may  be  required  for  feeding  the  patient.  If  the  tongue 
or  epiglottis  has  been  cut  loose  from  its  attachments  it  may  cause  asphyxia 
by  falling  upon  the  opening  of  the  glottis.  Sudden  oedema  of  the  glottis 
may  arise  as  a  complication  of  wounds  of  the  larynx.  These  complica- 
tions may  render  it  necessary  for  tracheotomy  to  be  performed,  lest 
between  the  visits  of  the  surgeon  death  may  occur  from  sudden  swelling 


548  RESPIRATORY    ORGANS. 

or  rather  obstruction  of  the  chink  of  the  glottis.  Emphysema  of  the 
neck  may  supervene  after  such  wounds  by  reason  of  air  escapintr  from 
the  respiratory  tract  into  the  subcutaneous  tissue.  Diti'use  cellulitis  of 
the  neck  may  follow  wounds  ;  and  septic  poisoning,  secondary  to  ulcera- 
tions in  the  nioutli  or  j)harynx,  to  scarlet  fever,  and  to  diphtheria,  is  not 
uncommon.  If  the  cellulitis  assumes  a  suppurative  character  free  inci- 
sion to  prevent  burrowinir  of  pus,  and  antiseptic  irrigation  of  the  cavities 
in  whicli  this  is  located,  are  urgently  demanded. 

Congenital  cysts,  called  hydroceles  of  the  neck,  are  due  to  the  embry- 
onic clefts  not  becoming  entirely  closed.  A  cavity  is  consequently  left 
which  is  tilled  with  Huid.  A  most  common  surgical  condition,  however, 
in  this  situation  is  glandular  enlargement  due  to  chronic  lymi)hadenitis. 
These  chronic  lymphatic  conditions  are  often  the  result  of  tubercular  in- 
fection and  are  very  liable  to  become  caseous  and  to  break  down  into 
puriform  fluid.  Acute  lymphadenitis  often  arises  as  a  complication 
from  diseased  teeth.  A  lymphatic  glandular  enlargement  situated  over  the 
submaxillary  or  parotid  salivary  gland  sometimes  acquires  considerable 
bulk,  and  is  liable  to  be  mistaken  for  tumor  or  malignant  disease  of  the 
salivary  gland.  Chronic  enlargement  of  the  lymphatic  glands  of  the 
neck  should  be  treated  by  constitutional  remedies,  such  as  tonics,  cod- 
liver  oil,  potassium  iodide,  a  residence  at  the  seashore,  and  attention  to 
hygienic  surroundings.  Locally  the  treatment  should  consist  of  counter- 
irritation  by  means  of  iodine  tincture  or  the  ointment  of  the  red  iodide 
of  mercury.  If  after  such  measures  they  continue  to  enlarge  it  may  be 
proper  to  excise  the  glands  before  they  have  undergone  puriform  change. 
This  is  desirable  because  they  may  become  the  primary  focus  from  which 
general  tubercular  infection  may  arise.  If  cheesy  or  puriform  degenera- 
tion has  taken  place  it  is  proper  to  incise  the  skin  over  the  softened  mass, 
to  scrape  away  with  a  curette  all  the  glandular  tissue  and  diseased  struc- 
ture around  it,  and  to  dress  the  wound  with  iodoform.  The  depressed 
scar  left  by  such  early  incision  is  less  deforming  than  the  irregular  and 
puckered  superficial  cicatrix  which  usually  remains  after  spontaneous 
evacuation  of  the  i)uriform  collection. 

The  unsightly  scars  left  by  the  occurrence  in  youth  of  such  cervical 
tubercular  lesions  may  be  made  almost  imperceptible  by  a  small  plastic 
operation.  An  elliptical  incision  is  made  around  the  depressed  cicatrix, 
the  skin  is  dissected  loose  for  some  distance  on  each  side,  and  the  edges 
are  then  drawn  together  by  sutures  over  the  intervening  depressed  por- 
tion of  skin,  which  has  previously  been  made  raw  by  scraping  with 
a  knife  edge.  Thus  the  cutaneous  structures  are  elevated  to  a  level  with 
the  surrounding  skin,  and  the  irregular  scar  converted  into  a  straight, 
white  line. 

Diseases  of  the  Thyroid  Body. 

The  function  of  the  thyroid  gland  is  probably  control  of  the  mucinoid 
substances  in  the  tissues,  the  regulation  of  albuminoid  metabolism,  and 
the  manufacture  of  blood  corpuscles.  Its  atrophy  or  entire  removal  is 
followed  by  the  condition  called  myxoederaa.  (Fig.'362.)  In  myxo^dema 
the  subcutaneous  tissue  of  the  patient  becomes  swollen  Avith  mucus.  This 
causes  a  condition  resembling  serous  oedema,  except  that  the  tumefac- 
tion is  harder.  The  patient's  lips  and  eyelids  become  puffy,  his  mind 
heavy,  his  speech  thick,  the  temperature  usually  subnormal  and  his  intel- 
ligence deficient  almost  to  a  condition  of  imbecility.     There  is  loss  of  the 


BRONCHOCELE     OR     GOITRE. 


549 


red  and  increase  of  the  white  corpuscles  of  the  blood.     The  condition,  as 
far  as  known,  is  unamenable  to  treatment,  and  is  finally  fatal.    It  has  been 
attributed  also  to  changes  in  the  sympa- 
thetic   nervous    system.     The    defective  Fig.  361. 
mental  state,   called  cretinism,  found  at 
times  with  goitre,  is  probably  due  to  the 
goitrous  affection  causing  atrophic  inter- 
ference with  the  function  of  the  thyroid 
body. 

Bronchocele  OR  Goitre. 


Myxcedema.     (Treves.) 


Tumors  of  the  thyroid  body  are  usu- 
ally included  under  the  head  of  bron- 
chocele  or  goitre,  although  in  a  strict 
sense  the  term  should  probably  be  em- 
ployed for  enlargements  of  the  gland  and 
not  to  its  infiltration  or  substitution  by 
morbid  growths.  The  thyroid  gland  iu 
women  not  infrequently  becomes  enlarged 
from  congestive  swelling  during  sexual  excitement,  pregnancy,  and  at 
menstruation.  The  congestive  enlargement  so  occurring  may  remain 
after  the  causative  factors  have  passed  away.  The  enlargement  may 
include  both  lobes  of  the  gland  as  well  as  the  isthmus,  or  it  may 
involve  either  lobe  or  the  isthmus  alone.  At  times  pulsation  occurs 
in  the  enlarged  gland  and  is  so  evident  as  to  simulate  aneurism.  In 
one  variety  of  congestive  goitre  there  is  protrusion  of  the  eyeballs  and 
irritability  of  the  heart  associated  with  the  enlargement  of  the  thyroid 
body.  This  condition  is  a  distinct  general  disease  called  exophthalmic 
goitre.  In  this  affection  the  thyroid  gland  is  swollen,  perhaps  tender  on 
pressure,  and  may  pulsate.  The  eyeballs  protrude  from  between  the  eye- 
lids, as  a  result,  probably,  of  vascular  congestion  in  the  post-ocular  tissue, 
and  the  heart's  action  is  irregular  and  feeble.  Often  there  is  a  murmur 
heard  at  the  cardiac  base.  The  patient  is  weak,  ansemic,  and  often  sub- 
ject to  anorexia  and  amenorrhcea.  Gradual  improvement  usually  takes 
place  under  effective  treatment  lasting  through  many  months.  Cases, 
however,  do  at  times  end  fatally. 

In  addition  to  the  congestive  enlargement  of  the  thyroid  body,  which  has 
been  described,  simple  hypertrophy  of  the  stroma  and  glandular  elements 
of  the  organ  may  occur.  Fibrous  and  cystic  changes  also  take  place  in 
this  organ,  giving  a  form  of  goitre  corresponding  to  these  alterations. 
Simple  hypertrophic  goitre,  which  is  really  a  fibro -adenomatous  change, 
may  follow  the  congestive  form.  The  patient  presents  symptoms  not 
unlike  those  of  exophthalmic  goitre,  except  that  the  ocular  and  cardiac 
symptoms  are  absent.  Interference  with  swallowing  and  respiration  may 
occur,  as  the  position  of  the  growth  may  produce  pressure  upon  the 
trachea  and  oesophagus.  Giddiness  may  be  induced  by  similar  intei'fer- 
ence  with  circulation  through  the  large  vessels  of  the  neck  going  to  and 
coming  from  the  brain.  In  fibrous  goitre  the  stroma  of  the  organ  in- 
creases more  markedly  than  does  glandular  tissue,  though  the  pathological 
alteration  is  similar  in  other  respects  to  the  simple  hypertrophy  just 
described.  The  thyroid  enlargement  may  be  soft  and  vascular  if  the 
growth  is  rapid,  or  hard  and  dense  if  the  change  is  more  chronic  in  its 
course.     The  fibrous  form  very  often  affects  but  one  lobe.     Its  displacing 


500  RESPIRATORY    ORGANS, 

pressure  is  very  likely,  therefore,  to  cause  lateral  deflection  of  the  trachea 
and  (esophagus.  As  the  thyroid  gland  lies  below  the  deep  fiiscia,  any 
enlargement  gives  rise  to  injurious  pressure  upon  the  other  organs  of  the 
neck,  as  has  been  indicated  above.  Such  pressure  is  more  apparent  when 
caused  by  a  hard,  rapidly  growing  fibrous  goitre  than  when  the  change 
is  one  of  the  other  varieties  of  bronchocele.  Flattening  the  calibre  of 
the  trachea  or  interference  with  the  normal  movements  of  the  tracheal 
rings  during  respiration  may  cause  a  tendency  to  dyspnoea.  The  ana- 
tomical attachment  of  the  isthmus  of  the  thyroid  body  to  the  trachea 
causes  the  gland  to  rise  and  fall  during  swallowing.  This  furnishes  a  test 
in  the  diagnosis  between  thyroid  enlargement  and  other  cervical  tumors. 
The  rise  and  fall  of  the  mass  during  deglutition  of  a  little  water  or  food 
indicate  at  once  the  thyroid  nature  of  the  growth,  since  enlargement  of 
the  Ivmphatic  glands  in  the  cervical  region  or  other  tumors  of  the  neck 
would  in  most  cases  not  be  affected  by  tracheal  movements.  One  or 
more  of  the  acini  of  the  gland  may  be  converted  into  a  cyst  or  cysts, 
filled  with  colloid,  serous,  or  bloody  fluid,  and  constitute  the  cystic  variety 
of  goitre.  While  the  wall  of  such  cysts  may  be  very  vascular  it  may  also  at 
times  become  calcified.  In  extreme  cases  the  whole  thyroid  body  may  be 
converted  into  a  series  of  cysts.  Goitre  is  endemic  in  certain  regions  of  the 
world,  especially  in  some  parts  of  England  and  in  the  Tyrol,  and  is  there 
often  associated  with  a  peculiar  deterioration  of  the  brain  called  cre- 
tinism. This  has  been  attributed  to  the  atrophy  of  the  gland  which 
accompanies  such  thyroid  tumors.  The  different  varieties  of  goitre  found 
in  these  persons  attain  at  times  enormous  bulk. 

Treatment. — The  treatment  of  goitre  differs  with  the  variety  of  the 
growth. 

The  treatment  of  exophthalmic  goitre  belongs  to  the  domain  of  medi- 
cine, and  consists  in  the  administration  of  iron,  digitalis,  and  similar 
remedies. 

The  treatment  of  congestive  growth  is  not  unlike  that  of  exophthalmic 
goitre,  and  consists  in  the  use  of  digitalis  and  tonics  internally,  and 
counter-irritation  by  means  of  tincture  of  iodine,  red  iodide  of  mercury 
ointment,  and  similar  preparations  externally.  Ergot,  ammonium  chlo- 
ride, and  potassium  iodide  have  been  advocated  in  this  form  of  goitre, 
and  are  probably  of  value  if  given  in  large  doses. 

In  fibrous  goitre  the  remedies  recommended  for  congestive  and  exoph- 
thalmic goitre  may  be  applied.  The  benefit  obtained,  however,  is  not  .so 
evident  in  this  form  of  bronchocele.  When  the  growth  is  large  and 
causes  pain  and  other  symptoms  of  pressure,  the  surgeon  should  make  a 
cut  through  the  deep  cervical  fascia,  which  will  permit  the  tumor  to  bulge 
forward,  thereby  relieving  pressure  on  the  important  structures  beneath 
it.  The  incision  may  be  open  or  subcutaneous,  according  to  circum- 
stances. When  this  procedure  is  not  effectual,  the  isthmus  of  the  thyroid 
gland  may  be  divided  in  the  middle  line  after  two  strong  ligatures  have 
been  applied  at  each  side  of  the  proposed  incision  to  prevent  hemorrhage. 
The  repeated  injection  of  alcohol  or  tincture  of  iodine,  in  ten  minim  doses 
directly  into  the  fibrous  tumor  by  means  of  a  hypodermic  syringe,  may 
diminish  the  bulk  by  causing  interstitial  absorption.  Cystic  goitres 
should  be  subjected  to  evacuation  by  puncturing  with  a  trocar  and 
canula,  and  subsequently  to  injections  of  tincture  of  iodine,  tincture  of 
the  chloride  of  iron,  or  a  solution  of  carbolic  acid,  if  the  simple  evacuating 
puncture  is  followed  by  reaccumulation  of  fluid.  Care  must  be  taken 
before  injecting  these  irritants  to  see  whether  blood  escapes  from  the 


BRONCHOCELE    OR     GOITRE.  551 

canula  after  the  tluid  in  the  cyst  has  been  allowed  to  flow  out.  If  blood 
flows,  it  is  an  indication  of  the  possibility  of  a  vein  having  been  punc- 
tured, and  the  point  of  the  canula  should  therefore  be  withdrawn  a 
little  before  the  injection  is  made.  It  is  not  safe,  however,  to  inject  such 
irritating  fluids  into  rapidly  growing  tumors,  since  they  are  apt  to  become 
violently  inflamed.  Suppuration  is  sometimes  induced  by  this  method  of 
treatment,  due  to  the  invasion  of  pyogenic  germs.  Spontaneous  abscess 
of  the  thyroid  gland  I  have  found  on  one  occasion.  It  should  be  treated 
by  free  incision,  in  order  that  the  pus  and  the  suppurating  tissue  may  be 
evacuated  and  removed.  Excision  of  the  thyroid  gland  has  been  done  in 
cases  where  the  size  of  the  growth  and  its  pressure  symptoms  have  ren- 
dei-ed  the  operative  risk  of  such  an  operation  justifiable.  According  to 
Horsley,  excision  of  more  than  one  lobe  must  not  be  performed,  since  re- 
moval of  the  whole  body  will  lead  to  myxoedema,  and  because  excision  of 
the  isthmus  or  of  one  lobe  will  usually  remove  the  urgent  symptoms. 


CHAPTER    XX. 


DISEASES  OF  THE  MOUTH. 


Harelip  is  a  term  applied  to  congenital  fissure  in  the  upper  lip,  and 
may  be  single  or  double.  The  fissure,  however,  is  always  a  little  to  one 
side  of  the  middle  line,  in  a  position  corresponding  with  the  suture  be- 
tween the  intermaxillary  bone  and  the  upper  jaw  of  the  corresponding 
side.  When  harelip  is  double,  a  small  portion  of  the  lip  lies  between  the 
fissures.  This  central  lobule  may  be  very  poorly  developed ;  in  fact,  it 
may  be  scarcely  more  than  indicated,  thus  giving  a  double  harelij)  the 
appearance  of  a  single  cleft  in  the  median  line.  The  inter-maxillary  bone, 
which  carries  the  incisor  teeth,  may  be  se|)arated  from  tlie  upper  maxil- 
lary bone  of  the  same  side  by  a  cleft  which  corresponds  with  the  cleft  in 
the  lip.     This  is  one  of  the  forms  of  cleft  palate. 

Cleft  of  the  palate  is  a  congenital  defect,  corresponding  in  character 
■with  harelip,  occupying  the  hard  or  soft  parts  of  the  palate,  or  both.    All 

of  these  conditions  are  due  to 
defect  in  coalescence  some  time 
about  the  ninth  week  of  foetal 
life.  When  the  alveolus  is  cleft 
and  the  intermaxillary  bone  is 
separated  from  the  other  portions 
of  the  jaw  by  such  congenital  de- 
fect, the  harelip  is  often  compli- 
cated by  protrusion  forward  of  the 

Fio.  .36.3. 


Fig.  .362. 


Single  and  double  harelip. 
(Treves  ) 


Diagram  of  incision  in  operation  for 
harelip. 


incisor  and  inter-maxillary  structures,  which  thus  extend  forward  below 
and  in  front  of  the  nose  as  a  sort  of  snout.  The  nostril  on  the  side  cor- 
responding with  the  harelip  is  usually  broadened  and  flattened,  by  reason 
of  the  ala  being  carried  outward. 

Harelip,  if  at  all  extensive,  prevents  the  infant  from  sucking  well. 
This  circumstance,  as  well  as  because  it  is  difficult  for  the  child's  lips  to 
be  kept  at  rest  after  it  has  learned  to  speak,  renders  it  proper  to  operate 
when  the  child  is  between  six  weeks  and  three  months  of  age,  provided, 
of  course,  that  the  general  health  is  good. 

The  plastic  operation  for  harelip  consists  in  separating  the  upper  lip 


HARELIP.  553 

from  the  gum  ;  in  paring  the  edges  of  the  fissure,  and  in  bringing 
them  together  with  pin  sutures  in  such  a  way  as  to  leave  no  defect  in  the 
vermilion  border  of  the  lip.  Union  by  first  intention  is  usually  obtained, 
if  the  operation  is  well  done  and  the  parts  so  arranged  that  thei-e  is  no 
tension  upon  the  sutures.  The  child  may  be  held  in  the  nurse's  lap  with 
his  head  placed  between  the  two  knees  of  the  sitting  surgeon,  or  it  may 
be  placed  upon  an  operating  table.  Ether  is  usually  given.  Compres- 
sion forceps  may  be  used  upon  the  upper  lip  near  the  corners  of  the 
mouth  to  prevent  bleeding  from  the  coronary  arteries.  A  straight,  nar- 
row knife  is  then  used  to  transfix  the  tissues  on  each  side  of  the  cleft  and 
to  pare  away  the  borders  beginning  high  up  in  the  nostrils  at  the  angle 
of  the  fissure.  Sufiicient  tissue  must  be  removed  to  make  a  wide  raw 
surface  on  both  edges  of  the  cleft,  so  that  when  the  lip  is  brought  together 
there  will  be  a  wide  surface  of  contact  to  cause  union.  The  strip  cut  off 
may  be  entirely  removed  or  a  portion  may  be  retained  at  the  lower  part 
in  order  to  make  the  free  margin  of  the  lip  bulge  a  little  when  the  sutures 
are  placed.  It  is  often  well  to  carry  the  lower  end  of  the  incision  a  little 
away  from  the  cleft  and  then  turn  the  knife  toward  the  middle  line  so  as 
to  leave  a  tag  of  tissue  covered  with  mucous  membrane. 

The  accompanying  diagram  (Fig.  363)  shows  this  incision,  which  is 
made  in  order  that  the  parts  which  are  brought  together  may  pout  a 
little,  and  prevent  the  occurrence  of  a  slight  notch  in  the  edge  of  the 
reconstructed  lip. 

If  this  incision  is  not  adopted  an  incision  concave  toward  the  cleft  is  a 
good  one,  because  when  the  concave  edges  are  brought  together  in  a 
straight  line  a  similar  pouting  on  the  margin  of  the  lips  is  accomplished. 
A  steel  pin  is  then  carried  through  the  two  portions  of  the  lip  and  across 
the  gap  just  beneath  the  wing  of  the  nose.  The  flattened  condition  of 
the  nostril  is  thus  corrected  by  the  same  pin  which  brings  the  upper  part 
of  the  gap  in  the  lip  together.  A  second  pin  is  introduced  about  the 
middle  cleft,  care  being  taken  to  pass  it  between  the  mucous  membrane 
and  the  coronary  ai-tery,  in  order  that  the  pressure  made  shall  arrest 
bleeding.  The  forceps  previously  applied  to  prevent  bleeding  are  now 
removed.  Catgut  or  silk  sutures  are  then  carried  around  the  ends  of 
each  one  of  these  pins  to  bring  the  parts  in  apposition.  A  few  fine  catgut 
or  silk  sutures  are  used  along  the  margin  of  the  lip  and  upon  the  internal 
surface,  in  order  to  bring  the  mucous  membrane  into  accurate  apposition. 
It  is  very  important  that  the  mucous  membrane  and  the  skin  should  be 
accurately  matched  at  the  muco-cutaneous  border  as  deformity  is  some- 
times produced  by  having  the  mucous  membrane  run  up  higher  on  one 
side  of  the  repaired  cleft  than  upon  the  other.  This  is  a  very  unsightly 
deformity  after  union  has  taken  place. 

The  wound  is  dressed  with  iodoform  and  collodion,  and  the  child  is 
fed  either  at  the  breast  or  with  a  spoon.  The  pins  are  taken  out  upon  the 
third  day,  although  the  ligatures  are  allowed  to  adhere  to  the  incision,  in 
order  to  assist  in  supporting  it  for  a  few  days  longer.  The  sutures  in  the 
mucous  membrane  may  be  allowed  to  remain  until  the  fourth  or  fifth  day. 
The  operation  for  double  harelip  is  the  same.  Both  clefts  are  pared  and 
corrected  at  once,  pins  being  passed  through  the  flattened  edges  of  the 
lip  and  through  the  central  lobule  if  it  be  large  enough  to  be  of  any  ser- 
vice in  filling  the  gap.  The  edges  of  this  central  lobule  are,  of  course, 
freshened ;  but  if  it  is  very  short  it  may  be  necessary  to  preserve  the 
parings  from  the  lateral  margins  of  the  cleft  and  to  use  them  in  filling  up 
the  gap  below  the  central  portion  of  the  lip  when  the  final  sutures  are 
applied. 


554  DISEASES    OK    THE    MOUTH. 

In  case  of  absence  of  tlie  nasal  colinnelhi  as  a  complication  it  may  be 
wise  to  turn  up  the  central  process  of  the  lip  to  reconstruct  the  deficiency 
in  the  nose.  If  the  inter-maxillary  bone  or  its  alveolar  portion  protrudes 
it  may  be  cut  away  with  bone  forceps  or  bent  up  into  place  after  fractur- 
ing its  attachments.  The  vomer,  which  is  sometimes  hypertrophied  when 
this  protrusion  is  present,  may  be  retrenched  by  excision  of  a  V-shaped  por- 
tion behind  the  intor-maxillary  bone.  No  attempt  is  made  to  correct  the 
cleft  in  the  alveolar  process,  since  the  defect  is  covered  by  the  lip  andean 
be  remedied,  when  the  child  has  reached  adult  life,  by  artificial  dentures. 
If  union  by  first  intention  fails  in  attempts  at  curing  harelip,  it  may  be 
necessary  to  do  a  secondary  operation,  in  order  to  get  a  perfect  result. 


/  Cleft  Palate. 

Cleft  palate,  which  is  similar  in  its  origin  to  harelip,  is  much  more  diffi- 
cult to  repair  by  plastic  procedures.  The  cleft  is  in  the  middle  line  except 
when  it  is  in  the  anterior  portion  of  the  hard  palate,  w^hen  it  may  be  a 
little  to  one  side  of  the  middle  line.  The  fissure  may  sometimes  be  double 
in  front  with  the  incisive  bone  lying  between  the 
two  clefts.  It  is  more  common,  however,  to  have 
only  the  soft  parts  of  the  palate  fissured.  The 
operation  for  the  repair  of  the  soft  palate  is  called 
staphylorrhaphy,  while  a  similar  operation  on  the 
hard  palate  is  called  uranoplasty.  Cleft  palate 
interferes  with  deglutition  and  speech,  because  it  is 
usually  impossible  for  the  patient  to  close  the  pos- 
terior nares,  which  is  essential  in  proper  deglutition 
and  speaking.  In  infants  deglutition  is  often  very 
difficult  and  the  milk  is  regurgitated  into  the  nasal 
cavities.  These  conditions  are,  of  course,  greater 
Fissure  orsofTand  hard  ^vhen  the  cleft  is  a  large  one  or  involves  both  the 
palate.    (Smith.)  hard  and   soft  palates.     In   the  milder  form  the 

child,  when  beginning  to  talk,  should  be  especially 
trained  in  articulation  ;  as  by  special  development  of  the  muscles  he 
may  be  able  to  overcome  this  defect  in  speech  to  a  great  extent.  In  more 
severe  cases  benefit  may  be  derived  by  applying  to  an  oral  surgeon  for 
the  adaptation  of  an  artificial  palate.  Artificial  palates,  however,  are 
not  sufficiently  satisfactory  to  prevent  the  adoption  by  many  of  operative 
proceedings  in  great  palatal  defects. 

The  operation  for  cleft  palate  to  be  most  successful  should  be  done 
before  the  child  has  fully  acquired  the  art  of  speech.  About  the  third 
year  is  the  proper  time.  If  the  patient  is  young  he  should  be  etherized, 
but  in  adults  the  use  of  cocaine  will  render  general  ansesthesia  unneces- 
sary. The  mouth  must  be  held  open  bv  means  of  a  gag.  The  edges  of 
the  cleft,  when  the  fissure  involves  only  the  soft  palate,  should  be  carefully 
pared,  from  the  angle  of  the  fissure  backward  to  the  free  margin  of  the 
velum,  after  which  the  two  sides  of  the  velum  must  be  brought  together 
by  silk  or  wire  sutures  passed  by  means  of  a  curved  needle. 

Before  passing  the  sutures  in  the  operation  of  staphylorrhaphy  it  is  well, 
in  cases  where  the  cleft  is  large,  to  cut  the  two  elevator  and  tensor  mus- 
cles of  the  palate,  in  order  to  diminish  tension  on  the  soft  palate,  which 
is  about  to  be  drawn  together.  This  is  done  by  passing  a  tenotome  through 
the  soft  palate  on  the  inner  side  of  the  hamular  proce&s,  which  can  be  felt 


EPITHELIOMA     OF    THE    LIP.  555 

at  the  outer  side  of  the  roof  of  the  mouth,  and  carrying  the  edge  of  the 
tenotome  upward  and  then  downward,  thus  dividing  the  muscles.  The 
flaccid  and  immobile  condition  produced  by  the  division  of  these  muscles 
will  prove  that  the  division  has  been  successful.  The  sutures  are  then 
passed  and  tied.  During  the  after-treatment  the  j^atient  should  be  pre- 
vented from  coughing  or  talking,  and  fed  on  liquid  food. 

In  the  operation  of  uranoplasty,  or  closure  of  cleft  in  the  bony  palate, 
two  strips  of  mucous  membrane  with  the  underlying  periosteum  are  sepa- 
rated from  the  hard  palate  on  each  side  of  the  fissure  and  drawn  toward 
the  middle  line,  where  they  are  held  together  by  sutures.  The  incisions 
for  raising  the  muco-periosteal  flaps  are  made  antero-posteriorly  near  the 
alveolar  process,  and  along  the  edge  of  the  cleft.  The  flaps  are  then  dis- 
sected up,  but  are  left  attached  at  both  ends.  The  middle  portions  of  the 
strips  are  then  pushed  laterally  toward  the  middle  line  and  sutured, 
while  the  raw  surfaces  left  by  their  removal  heal  by  granulation.  The 
soft  palate  is  repaired  as  described  above.  Some  surgeons  prefer  to  cut 
entirely  through  the  hard  palate  with  a  chisel  and  displace  the  detached 
portions  of  bone  toward  the  median  line.  If  preferred  by  the  operator, 
the  patient's  head  may  be  allowed,  in  operations  on  the  palate,  to  hang 
over  the  end  of  the  table,  so  that  the  roof  of  the  mouth  is  below  the 
operator.  The  blood  then  runs  into  the  nose  and  does  not  obscure  the 
field  of  work. 

Operations  for  the  relief  of  cleft  palate,  even  Avhen  extensive,  are  often 
quite  successful,  but  at  best  they  make  a  rather  poor  substitute  for  the 
normal  roof  of  a  mouth.  Subsequent  to  their  use,  careful  training  of  the 
child  in  articulation  is  very  important. 

Epithelioma  of  the  Lip. 

Herpes,  ulcerations  of  the  non-malignant  kind,  and  inflammatory  fis- 
sures or  cracks  in  the  lip  belong  to  medicine.  Epithelioma,  however,  is 
so  common  an  affection,  especially  among  men,  and  in  the  lower  lip,  that 
it  deserves  special  attention  at  this  point.  It  is  possible  that  smoking  a 
clay  pipe,  and  similar  long-continued  irritations,  may  be  factors  in  the 
causation  of  this  malignant  disease.  The  upper  lip  is  occasionally  the 
seat  of  epithelioma.  At  first  the  variation  from  health  in  the  tissues  is 
so  slight  that  it  is  overlooked  ;  but  after  a  time  the  patient  notices  a  small 
hard  nodule,  which  subsequently  ulcerates,  or  an  intractable  ulcer  or  fis- 
sure appears  upon  the  lip  and  refuses  to  heal.  Induration  about  the  base 
of  the  lesion  steadily  and  gradually  increases  in  size,  and  a  little  later 
involvement  of  the  submaxillary  and  cervical  glands  gives  evidence  that 
the  disease  is  a  malignant  one.  Epithelioma  of  the  lip  does  not  cause 
much  pain ;  when  ulcerated  a  thin  discharge  is  secreted.  Death  may 
take  place  from  exhaustion  or  hemorrhage,  or  from  secondary  involve- 
ment of  the  internal  organs. 

Epithelioma  and  lupus  of  the  lip  are  sometimes  similar  in  appearance, 
but  the  latter  does  not  involve  the  cervical  and  submaxillary  glands. 
The  diagnosis  between  epithelioma  and  chancre  of  the  lip  is  exceedingly 
important.  Chancre  occurs  at  any  age,  while  epithelioma  is  more  common 
after  the  age  of  forty  years.  Chancre  begins  as  an  ulcer,  as  a  rule,  whereas 
epithelioma  ordinarily  begins  as  a  nodule.  In  the  syphilitic  affection  the 
lymphatic  glands  are  involved  earlier ;  and  the  sore,  even  when  it  attains 
its  maximum,  is  not  so  extensive  in  its  progress  as  the  cancerous  affection  ; 


556  DISEASES    OF    THE    MOUTH. 

and  in  atldition  tliere  may  he  some  syphilitic  fever.  Secondary  eruptions 
mav  also  appear,  to  assist  in  the  diagnosis  ;  and  most  important  of  all,  the 
syphilitic  sore  promptly  yields  to  mercurial  treatment.  Epithelioma  of 
the  lip,  before  secondary  involvement  of  the  internal  organs  hits  occurred, 
is  usually  exhibited  in  the  lymphatic  glands  under  and  behind  the  lower 
jaw.  The  original  site  of  disease  and  the  involved  glands  slowly  ulcerate, 
and  destruction  of  the  tissues  about  the  mouth  and  throat  is  finally  very 
extensive.  Labial  epithelioma  should  be  treated  by  prompt  and  radical 
operation,  except  when  the  disease  has  extended  as  indicated ;  then  pro- 
longation of  the  patient's  life  by  anodynes  and  supporting  measures  is  all 
that  can  be  done.  Excision  of  epithelioma  of  the  lip  is  accomplished  by 
the  removal  of  a  V-shaped  portion  of  tissue  with  the  base  of  the  wedge  at 
the  margin  of  the  lip.  During  the  operation  the  lip  is  held  everted  by 
an  a.-'sistant's  fingers,  which  also  press  upon  the  coronary  arteries  at  each 
side  of  the  proposed  incision.  The  excision  should  be  done  soon  enough 
to  insure  entire  removal  of  the  malignant  mass.  The  divided  lip  must 
then  be  brought  together  by  one  or  two  pin  sutures,  so  passed  as  to  make 
pressure  upon  the  coronary  arteries  and  prevent  bleeding.  Along  the 
edge  and  inner  surface  of  the  lip  the  mucous  membrane  should  be  united 
by  fine  catgut  sutures.  The  wound  should  then  be  dressed  with  a  little 
antiseptic  absorbent  cotton,  held  in  place  by  iodoform  and  collodion 
painted  upon  it.  It  may  be  necessary  in  more  extensive  infiltration  to 
cut  a  larger  portion  of  the  lip  away  and  to  construct  a  new  lip  from  the 
ti.ssues  covering  the  chin  by  slipping  up  one  or  too  large  cutaneous  flaps. 
Excision  of  a  portion  of  the  jaw  is  required  if  the  disease  has  in- 
volved the  bone  tissue.  Enlarged  glands  under  the  jaw  and  in  the 
neck  should  be  removed  at  the  same  operation.  The  prognosis  after 
excision  of  epithelioma  of  the  lip  is  usually  quite  good,  if  the  portion 
attacked  permits  of  free  removal.  If  the  growth  returns,  it  should  be 
removed  a  second  time. 


Tumors  of  the  Mouth. 

Tumors  of  various  kinds  may  be  found  upon  the  buccal  surface  of 
the  cheeks  and  in  the  floor  of  the  mouth.  The  most  common  form, 
perhaps,  is  the  cystic  tumor,  occurring  beneath  the  tongue  and  usually 
upon  one  side  of  the  fraenum,  to  which  the  term  ranula  is  usually  ap- 
plied. Ranulaj  contain  a  more  or  less  transparent,  gelatinous  fluid,  re- 
sembling saliva.  They  are  sometimes  dilated  ducts  of  the  submaxillary 
or  sublingual  glands,  and  at  other  times  occur  as  dilatations  of  the  ducts 
of  the  raucous  glands  in  the  floor  of  the  mouth.  True  hydatid  cysts  have 
been  found  here,  and  the  bursa  above  the  hyoid  bone  has  been  known 
to  become  enlarged,  and  resemble  ranula.  These  cystic  tumors  are  soft, 
elastic  swellings,  which  gradually  increase  in  size.  They  sometimes  be- 
come so  large  as  to  push  out  the  tissue  of  the  neck  below  the  jaw  and 
make  a  distinct  bulging  upon  the  exterior  of  the  throat.  Adipocere 
and  rice-like  bodies  have  at  times  been  found  in  ranuUe. 

The  treatment  of  these  non-malignant  growths  consists  in  puncturing 
the  sac  so  that  evacuation  of  fluid  takes  place,  and  then  setting  up 
sufiicient  irritation  of  the  lining  membrane  to  cause  obliteration  of  the 
cavity.  This  last  object  may  be  obtained  by  scraping  the  interior  of 
the  sac  with  the  trocar  and  canula  with  which  its  fluid  contents  have 
been  withdrawn,  or  by  laying  open  the  sac  with  a  knife  and  mopping 


TUMORS    OF    THE    JAW.  557 

out  its  interior  with  chloride  of  zinc  or  carbolic-acid,  solution.  Some 
surgeons  prefer  to  operate  by  making  an  opening  in  the  cyst  wall,  and 
keeping  the  orifice  patulous  by  turning  a  portion  of  the  wall  inward 
and  stitching  it  with  its  internal  surface  toward  the  interior  of  the  sac. 
A  seton  may  be  passed  through  the  sac,  so  as  to  evacuate  its  contents 
and  give  rise  to  plastic  adhesion  of  its  walls.  Large  cysts  projecting 
externally  may  require  to  be  attacked  by  incision  in  the  neck.  After 
evacuation,  the  cavity  of  the  cyst  is  then  stuffed  with  antiseptic  gauze. 
It  is  occasionally  possible  to  dissect  out  the  cyst  by  means  of  external 
incision. 

Alveolar  Abscess. 

Abscesses  of  the  alveolar  process  may  be  superficial,  when  they  are 
called  gum-boils,  or  deep,  when  the  pus  originates  in  the  tissues  around 
the  root  of  a  tooth.  Abscesses  occurring  in  the  tooth  sockets  are  usually 
due  to  disease  of  the  teeth,  as,  indeed,  is  usually  the  case  in  superficial 
abscess.  The  pus  in  superficial  abscess  is  not  confined  by  bony  tissue,  as 
in  the  deeper  form,  and  is,  therefore,  the  seat  of  but  moderate  pain.  In 
those  cases  in  which  the  pus  is  confined  in  the  dense  walls  of  the  tooth 
sockets  the  pain  is  excruciating,  and  is  only  relieved  when  the  pus  is 
evacuated  either  spontaneously  or  by  drilling  the  bone  or  the  tooth.  Re- 
moval of  a  filling  which  has  been  previously  placed  in  a  carious  cavity 
in  the  crown  of  the  tooth  by  the  dentist  may  afford  exit  to  the  confined 
pus.  Escape  of  the  pus  gives  instant  relief  from  pain.  When  the  pus 
does  not  thus  find  its  way  through  the  bone  in  which  the  tooth  is  lodged, 
it  may  finally  be  evacuated  alongside  of  the  tooth  after  it  has  reached  the 
upper  edge  of  the  socket.  Occasionally,  the  suppurative  process  gives 
rise  to  a  fistulous  opening  in  the  cheek  or  in  the  roof  of  the  mouth,  and 
may  even  cause  destruction  of  the  palate  bone  and  penetrate  into  the 
nasal  cavity. 

The  treatment  of  alveolar  abscess  consists  in  the  use  of  leeches  locally 
to  the  gum  ;  painting  the  gum  with  tincture  of  aconite  root ;  the  applica- 
tion of  heat  and  moisture,  which  is  best  accomplished  by  the  use  of  a  hot 
fig  or  raisin  applied  to  the  gum ;  incision  of  the  gum,  and,  in  deep  abscesses, 
boring  of  the  bone  or  tooth,  in  order  to  permit  the  escape  of  pus.  In  many 
instances  the  tooth  should  be  seen  by  a  competent  dentist,  since  removal 
of  the  filling  and  treatment  of  the  abscess  cavity  through  the  tooth  may 
hasten  cure  and  preserve  the  structure. 

Acute  subperiosteal  abscess  may  occur  in  connection  with  alveolar 
inflammation,  and  lead  to  more  or  less  extensive  destruction  of  the  bone 
by  necrosis.     Early  and  thorough  incision  is  the  proper  treatment. 

TUMOES   OF   THE   JaW. 

Growths  involving  the  alveolar  process  of  the  jaw,  but  not  the  bone 
very  extensively,  have  long  been  given  the  name  epulis.  This  term, 
however,  should  be  discarded,  since  it  has  no  strict  definition,  and  many 
cases  of  so-called  epulis  would  be  better  understood  and  more  effectively 
treated  if  called  tumors  of  the  jaw  and  described  by  their  proper  adjec- 
tive as  fibromatous,  sarcomatous,  and  carcinomatous.  The  common 
growth  to  which  the  term  epulis  is  applied  is  a  fibrous  mass,  usually  if 
not  always  arising  from  the  periosteum  or  bone,  and  presenting  itself  as 
a  smooth,  firm,  elastic  growth  alongside  of  or  between  the  teeth.     It  may 


558  DISEASES    OF    THE    MOUTH. 

become  ulcerated.  These  fihronuis  are  more  common  in  the  lower  than 
in  the  upper  jaw,  and  they  appear  to  l)e  due  to  the  irritation  caused  by 
decaved  teeth.  .Such  Hl)roma.s  rshould  be  removed  by  operation  within 
the  mouth  in  order  that  the  scar  may  not  appear  upon  the  cheek.  They 
are  ordinarily  easily  cut  away  with  a  strong  knife  or  gouge,  though  it 
may  be  necessary  to  extract  one  or  more  teeth  in  order  to  make  the 
extirpation  complete.     They  are  not  apt  to  return. 

Malignant  tumors  of  the  jaw,  whether  occupying  the  alveolus,  and 
therefore  being  a  form  of  epulis,  or  arising  from  the  central  portion  of 
the  jaw-bone  and  gradually  extending  to  the  surface,  should  be  removed 
by  very  free  incision  tlirough  the  soft  tissue  and  bone.  Such  malignant 
growths  require  total  or  partial  excision  of  the  jaw.  the  amount  of  bone 
removed  depending  upon  the  time  at  which  the  operation  is  done.  In 
some  instances  it  is  sufficient  to  cut  away  the  upper  margin  of  the  lower 
jaw  without  making  the  section  complete.  .Similar  tumors  affecting  the 
upper  jaw  may  require  its  comj)lete  or  partial  resection. 

Non-nialignant  growths  of  the  jaws,  as  has  been  stated,  may  refjuire 
only  partial  excision  of  the  bone,  or  possibly  may  be  enucleated  without 
taking  away  much  of  the  bone  tissue.  Malignant  disease,  however, 
whether  it  involve  the  upper  or  lower  jaw,  should  be  removed  by  very 
free  incisions  and  by  enucleating  any  of  the  lyniphatic  glands  which  may 
be  secondarily  involved.  Where  it  is  impossible  to  get  beyond  the  recog- 
nized limits  of  the  disease,  operation  may  be  unjustifiable,  although  some 
instances  seem  to  indicate  that  removal  of  the  major  portion  of  the 
growth  by  means  of  a  knife  and  the  application  of  chloride  of  zinc  solu- 
tion to  the  surface  left  may  be  followed  by  prolongation  of  life. 

Cystic,  as  well  as  solid,  growths  may  develop  within  the  antrum  or 
cavity  of  the  upper  jaw  bone.  Such  tumors  occasion  great  deformity  as 
the  growth  pushes  the  walls  of  the  antrum  into  the  neighboring  fossje, 
or  outward  upon  the  face.  By  this  means  the  eyeball  may  be  protruded 
because  the  floor  of  the  orbit  is  raised ;  the  nasal  chamber  may  be 
occluded  by  the  growth  ;  the  hard  and  soft  palate  may  be  pushed  down- 
ward, and  the  face  may  be  deformed  by  protrusion  of  the  cheek.  Diffi- 
culty in  breathing  and  difficulty  in  swallowing  may  result  from  such 
antral  growths.  Cerebral  complications  may  also  occur,  as  well  as  blind- 
ness and  profuse  nasal  hemorrhage.  Solid  growths  in  the  antrum  are  to 
be  distinguished  from  cystic  growths  by  their  firmness,  and  by  the  fact 
that  in  the  latter  case  fluid  is  evacuated  when  the  antrum  is  tapped  from 
within  the  mouth  above  the  canine  tooth.  Rapidity  of  growth  occurring 
in  persons  beyond  the  middle  age  and  involvement  of  the  submaxillary 
and  other  lymphatic  glands  suggests  that  the  tumor  is  malignant  rather 
than  benign.  This  diagnosis  is  confirmed  when  rapid  infiltration  occurs 
outside  the  bony  walls  of  the  antrum,  because  it  indicates  that  the  malig- 
nant tumor  has  involved  the  bony  walls  and  spread  to  the  soft  tissues. 

Cystic  tumors  within  the  antrum  may  owe  their  origin  to  the  abnormal 
development  of  a  tooth  within  the  antral  cavity.  Such  dentigerous  cysts 
are  not  uncommon. 

Necrosis  of  the  Jaw. 

Necrosis  of  the  jaw  is  not  uncommon  in  those  exposed  to  the  fumes  of 
phosphorous  acid  in  the  manufacture  of  matches.  It  is  probable  that 
this  disea.se,  called  phosphorus  necrosis,  occurs  only  when  the  patient  is 
the  subject  of  diseased  teeth.     The  necrotic  portion  of  bone  should  be 


INFLAMMATION    OF    THE    TONGUE.  559 

removed  by  operation  within  the  mouth  so  as  to  avoid  a  scar.  This 
should  not  be  done  ordinarily  until  the  sequestrum  has  become  detached, 
because  it  is  desirable  to  retain  the  integrity  of  the  arch  of  the  jaw-bone 
which  in  earlier  attempts  at  removal  may  be  fractured.  Where  the 
sequestrum  is  very  large  it  may  be  necessary  to  make  an  external  incision. 
The  application  of  artificial  dentures  to  the  defective  bone  after  the 
removal  of  such  large  portions  may  give  a  useful  lower  jaw. 

Actinomycosis  is  a  disease  due  to  a  parasitic  fungus  which  has  been 
known  to  attack  the  jaws  and  to  be  the  cause  of  necrosis.  Necrosis  also 
occurs  secondarily  to  some  of  the  essential  fevers,  and  as  a  symptom  of 
tuberculosis,  syphilis,  injuries,  diseased  teeth,  and  excessive  mercurializa- 
tion.  Ankylosis  and  articular  disease  of  the  temporo-maxillary  joint 
have  been  discussed  elsewhere. 

Diseases  of  the  Tongue. 

When  the  frsenum  of  the  tongue  is  abnormally  short,  preventing  the 
protrusion  of  the  tip  beyond  the. teeth,  and  limiting  its  movements  within 
the  mouth,  tongue-tie  is  said  to  be  present.  This  condition  sometimes 
prevents  a  young  child  from  suckling,  and  in  older  children  interferes 
with  perfect  articulation.  Tongue-tie,  however,  does  not  prevent  speech 
and  make  a  child  dumb,  as  is  sometimes  supposed  by  the  laity. 

AVhen  tongue-tie  exists  to  any  marked  extent  it  should  be  remedied  by 
clipping  the  edge  of  the  fraenum  with  the  scissors.  The  incision  should 
be  about  one-eighth  of  an  inch  deep.  The  surgeon's  finger  can  then  tear 
the  tissue  and  establish  lingual  movements.  The  ranine  arteries  lie  in 
the  frsenum  close  to  the  lower  surface  of  the  tongue.  Division  of  these 
vessels  is  avoided  by  keeping  the  point  of  the  scissors  turned  downward. 
Reunion  of  the  cut  portions  of  the  frsenum  should  be  prevented  by  sepa- 
rating them  daily  Avith  a  probe  or  with  the  finger.  The  edges  of  the 
slight  wound  will  have  cicatrized  in  four  or  five  days. 

Inflammation  of  the  Tongue. 

Glossitis,  or  inflammation  of  the  tongue,  may  be  acute  or  chronic, 
simple  or  specific.  Simple  or  superficial  inflammation  of  the  mucous 
membrane  of  the  tongue  occurs  in  connection  with  stomatitis  or  inflam- 
mation of  the  mouth.  Stomatitis  is  applied  to  inflammation  of  the 
mucous  membrane  lining  the  cheeks,  lips,  and  other  oral  structures.  It 
may  arise  from  digestive  disorders,  the  administration  of  iodine,  mercury, 
and  other  drugs,  and  as  a  lesion  of  secondary  syphilis.  Mucous  patches 
and  erythema  are  the  pathological  conditions  of  the  mouth  most  prone  to 
follow  syphilis.  It  must  be  remembered  that  chancre  itself  may  be  fouud 
in  the  mouth.  Syphilis  may  be  exhibited  by  mucous  patches  or  gummy 
deposits  or  ulceration  in  the  tongue.  General  parenchymatous  inflam- 
mation of  the  body  of  the  tongue  of  an  acute  kind  occasionally  occurs, 
and  is  quite  a  serious  condition.  It  may  be  due  to  wounds  or  to  insect 
bites,  or  it  may  occur  without  apparent  cause.  The  tongue  is  swollen 
and  red  and  shows  a  smooth  surface.  Pain,  which  is  great,  is  perhaps 
increased  during  efforts  at  taking  food.  The  flow  of  the  saliva  is  abun- 
dant and  the  interference  with  respiration  may  be  marked.  The  condi- 
tion is  occasionally  followed  by  sloughing. 

Syphilitic  glossitis  requires  constitutional  treatment  and  local  stimu- 


/ 


560  DISEASES    OF    THE    MOUTH. 

lating  applications.  Acute  ])arenchyiiiat()us  ^'lossitis  should  be  treated  by 
leeches  applied  under  the  jaw  externally  and  the  use  of  cracked  ice  in 
the  mouth,  while  the  jiatient  is  nourished  with  liipiid  food.  If  these 
means  do  not  relieve  the  swelling  and  the  inflammatory  symptoms, 
incision  should  be  made  in  the  tongue  to  the  depth  of  one  half  inch  along 
each  side  of  the  middle  line,  beginning  well  back  upon  the  dorsum  of  the 
tongue,  and  extending  nearly  but  not  quite  to  the  tip.  The  relief  from 
tension  and  swelling  given  by  this  incision  will  usually  be  immediate. 
Antiseptic  mouth-washes  should  be  freely  used  thereafter. 

Injuries  to  the  tongue  and  the  impaction  of  foreign  bodies  in  the  organ 
give  rise  at  times  to  acute  or  chronic  suppurative  inflammation  or  abscess 
of  the  tongue.  If  the  puriform  fluid  lies  deeply  in  the  organ  the  chronic 
abscess  niav  be  surrounded  with  infiltrated  tissue  sufficiently  hard  to 
cause  re.«emblance  to  a  tumor  imbedded  in  the  lingual  muscles.  Such 
abscesses  of  the  tongue  are  treated  by  incision  and  the  removal  of  more 
or  less  insjiissated  puriform  fluid  with  the  curette.  Chronic  abscess  is 
probably  tubercular  in  its  etiology. 

In  addition  to  these  forms  of  glossitis  there  occurs  a  chronic  superficial 
inflammation  to  which  the  names  leucoma,  psoriasis,  and  ichthyosis  have 
been  applied. 

Epithelioma  of  the  Tongue. 

Various  benign  and  malignant  tumors  may  occur  in  the  tongue,  but  the 
most  common  of  all  is  epithelioma,  which  is  a  disease  with  distressing 
symptoms.  It  is  more  frequent  in  man  than  in  woman,  is  a  disease  of 
rather  advanced  life,  and  apparently  may  at  times  arise  secondarily  to 
superficial  glossitis.  Smoking,  the  immoderate  use  of  spirituous  drinks 
and  of  condiments,  irritation  from  jagged  teeth,  as  well  as  syphilis,  have 
been  suggested  as  possible  predisposing  causes. 

Epithelioma  of  the  tongue  appears  usually  on  one  side  of  the  middle 
line  toward  the  root  of  the  organ.  Superficial  ulceration  with  indurated 
base  and  edges  is  an  early  evidence  of  the  disease.  The  pain  is  at  first 
slight,  but  the  discomfort  increases  during  eating  and  other  movements, 
until  it  becomes  very  great.  The  saliva  flows  more  freely  and  the  breath 
becomes  fetid.  The  floor  of  the  mouth  and  fauces  become  involved,  as 
do  also  the  lymphatic  glands  below  the  angle  of  the  jaw.  Slight  or  pro- 
fuse hemorrhage  may  occur.  Impaired  nutrition,  due  to  the  diflSculty  in 
feeding  and  the  swallowing  of  foul  secretions,  is  soon  evident.  If  one  of 
the  lingual  arteries  is  opened  by  ulceration,  fatal  hemorrhage  probably 
supervenes,  while  death  may  also  occur  from  septic  pneumonia,  due  to 
inhalations  of  the  secretions  from  the  malignant  growth. 

The  diagnosis  between  epithelioma  of  the  tongue  and  ulcerative  syphi- 
litic gumma  is  at  times  difficult,  but  the  doubt  can  easily  be  cleared  up  by 
the  use  of  mercury  and  potassium  iodide  in  full  doses.  Specific  disease 
under  this  treatment  will  soon  show  evi<lence  of  improvement. 

The  only  effective  treatment  for  epithelioma  of  the  tongue  is  early  and 
complete  removal  of  the  whole  tongue  and  of  any  lymphatic  glands  below 
the  jaw,  which  may  be  involved.  Where  the  disease  has  progressed  to 
the  involvement  of  the  floor  of  the  mouth  before  the  surgeon  is  consulted 
it  may  be  doubtful  whether  operation  is  justifiable.  In  such  a  case  liga- 
tion of  both  lingual  arteries  may  possibly  retard  the  development  of  the 
growth,  and  excision  of  a  portion  of  the  lingual  nerve  on  the  side  affected 
may  relieve  pain.     This  nerve  can  be  felt  in  the  mouth  lying  underneath 


EPITHELIOMA    OF    THE    TONGUE.  561 

the  mucous  membrane  at  the  angle  of  the  lower  jaw,  vertically  below  the 
second  lower  molar  tooth.  An  incision  through  the  mucous  membrane 
W'ill  enable  the  operator  to  take  up  the  nerve  by  means  of  a  hook  and  to 
excise  a  portion  of  it.  This  neurectomy  lessens  pain  and  diminishes  the 
uncomfortable  flow  of  the  saliva.  The  pain  which  makes  lingual  move- 
ments distressing  may  also  be  mitigated  by  painting  the  diseased  tissue 
with  cocaine,  about  forty  grains  to  the  ounce.  The  patient  may  require 
feeding  by  enemas,  or  by  having  a  tube  passed  through  the  nostril  into 
the  pharynx.  CEsophagotomy  may  be  available  for  feeding  in  cases  where 
the  fauces  are  obstructed  by  the  growth. 

It  has  been  proposed  to  perform  tracheotomy  in  order  to  prevent  inhala- 
tion of  the  foul  discharges  which  give  rise  to  septic  pneumonia.  This 
seems  scarcely  necessary,  since  the  free  use  of  antiseptics  with  frequent 
powdering  of  the  cancer  with  iodoform  will  preserve  a  fairly  clean  con- 
dition of  the  ulcer. 

The  tongue  can  be  entirely  removed  by  dragging  it  forward  while  the 
mouth  is  held  open  by  a  gag.  A  strong  string  passed  through  the  organ 
at  its  tip  will  give  the  operator  •  control  of  it,  and  enable  him  to  pull  it 
well  out  of  the  mouth,  and  by  successive  manipulations  with  the  scissors 
the  organ  can  be  cut  away  without  difiiculty,  and  the  spurting  vessels  tied 
as  they  are  divided.  It  is  well  to  have  a  ligature  of  silk  passed  through 
the  stump  and  brought  out  of  the  mouth  after  the  removal  of  the  organ, 
in  order  that  the  patient  may  not  be  sufibcated  by  the  base  of  the  tongue 
falling  backward  into  the  pharynx.  This  danger  does  not  exist  after 
twenty-four  hours  have  elapsed. 

It  is  often  advantageous  to  split  the  tongue  in  the  middle  line  antero- 
posteriorly  before  attempting  its  complete  removal  with  the  scissors.  So, 
also,  in  cases  where  the  ecraseur  is  applied  to  extirpate  the  organ,  it  is 
well  to  operate  upon  the  two  halves  successively.  Operation  with  the 
scissors,  however,  seems  more  surgical  and  accurate  than  that  by  means 
of  the  ecraseur,  because  the  direction  and  extent  of  the  incision  can  be 
better  regulated.  The  mouth  should  be  well  packed,  after  drying  of  the 
stump,  with  iodoform  gauze,  which  should  be  pushed  into  every  irregu- 
larity of  the  mouth,  and  retained  several  days  until  cicatrization  of  all 
the  surfaces  has  been  accomplished.  The  patient  should  not  be  allowed 
to  talk  or  take  food  by  the  mouth  for  a  week.  Alimentation  can  be  kept 
up  by  the  rectum. 

If  this  radical  operation  is  done  early  in  the  course  of  the  disease,  a 
considerable  prolongation  of  life  is  usually  secured.  It  is,  however,  bad 
surgery  to  attempt  partial  removal  of  the  organ  in  cases  of  malignant 
disease. 

Access  to  the  tongue,  in  order  to  accomplish  its  complete  removal,  may 
be  obtained  by  making  a  horseshoe  incision  in  the  throat  under  the  lower 
jaw,  going  through  the  floor  of  the  mouth,  or  by  making  a  straight  cut 
from  the  centre  of  the  lip  to  the  chin,  accompanied  by  division  of  the  jaw- 
bone with  a  saw  at  the  symphysis.  Ordinarily,  however,  the  method  first 
described — namely,  that  of  dragging  the  tongue  out  of  the  mouth — is 
efficacious. 

Subsequent  to  the  removal  of  the  tongue,  the  speech  is  not  so  imperfect 
as  would  be  expected. 

36 


562  DISEASES    OF    THE    MOUTH, 


Diseases  of  the  Tonsils. 

Tonsillitis,  or  (juinsy,  may  go  on  to  suppuration,  and  require  incision 
for  the  evacuation  of  pus.  A  sharp-pointed  bistoury  should  be  carried 
through  the  swollen  gland  and  the  surrounding  tissue  until  the  pus  col- 
lection is  entered.  Usually  the  abscess  is  localized  at  the  upper  point  of 
the  tonsil,  where  it  joins  the  soft  palate.  The  point  of  the  knife  must 
never  be  carried  outward,  since  the  internal  carotid  artery  lies  just  exter- 
nal to  the  gland.  Detergent  washes  should  be  used  after  the  operation. 
Relief  is  immediate.  A  solution  of  sodium  bicarbonate  has  been  highly 
lauded  as  an  application  in  quinsy  prior  to  the  stage  of  suppuration. 
Sv})hilitic  lesions  and  malignant  tumors  are  at  times  found  in  the  tonsil 
glands. 

Hypertrophy  of  the  tonsils  is  a  chronic  condition,  probably  inflamma- 
tory in  its  character,  which  is  often  seen  in  children.  These  enlarged 
tonsils  are  fre(|uently  associated  with  recurrent  attacks  of  inflammation  of 
the  throat,  and  it  is  possible  that  they  may  have  some  relation  to  local 
tubercular  infection.  The  increase  in  size  may  be  so  gi-eat  that  the 
enlarged  glands  extend  to  or  beyond  the  middle  line  of  the  fauces,  so 
that  the  opposite  growths  come  in  contact  and  result  in  mutual  pressure. 
Ulceration  of  the  masses  may  be  thus  induced.  The  disease  causes  ob- 
struction to  breathing  and  swallowing,  and  compels  the  child  to  keep  its 
mouth  open  almost  constantly,  and  to  snore  during  sleep.  When  the 
enlarged  glands  are  attacked  with  acute  inflammation,  the  difficulty  in 
breathing  may  approach  sufl^bcation. 

Fig.  .'?fi5. 


Tonsillotome. 

The  medical  treatment  of  enlarged  tonsils  consists  in  the  use  of  astringent 
gargles,  the  application  of  nitrate  of  silver,  improved  hygienic  surroundings, 
and  the  internal  administration  of  good  food,  cod-liver  oil,  iodide  of  iron, 
and  other  tonics.  Surgical  treatment  is  often  demanded  because  of  the 
inefficiency  of  these  measures.  It  consists  in  excision  of  a  portion  of  the 
enlarged  gland  by  means  of  a  guillotine  or  tonsillotome.  The  operation 
is  not  a  dangerous  or  painful  one,  and  may  be  done  to  very  young  chil- 
dren without  an  anicsthetic.  A  solution  of  cocaine  may  be  painted  upon 
the  surface  of  the  enlarged  tonsils,  if  the  child  is  very  sensitive.  Only 
that  portion  of  the  growth  which  projects  into  the  ring  of  the  tonsillo- 
tome, when  it  is  laid  over  the  organ,  should  be  removed.  Even  when 
only  a  comparatively  small  portion  is  cut  away  the  operation  is  successful, 
since  atrophy  of  the  hypertrophied  mass  is  vex-y  apt  to  occur  afterward. 
The  hemorrhage  is  only  very  slight  usually,  although  cases  have  been 
reported  in  which  it  has  been  profuse.  In  such  cases  it  is  proper  to 
seize  the  bleeding  point  with  a  hemostatic  forceps,  which  should  be  left 
in  position  for  a  few  hours.  Detergent  gargles  should  be  used  after  the 
operation. 

When  the  circular  knife,  to  which  the  name  guillotine  or  tonsillotome 
is  applied,  is  not  at  hand,  the  hypertrophic  tissue  may  be  cut  away  with 
a  probe-pointed  bistoury,  after  the  apex  of  the  mass  has  been  seized  with 


RETRO-PHARYNGEAL    ABSCESS.  563 

a  pair  of  toothed  forceps.     This  method  is  less  rapid,  and  more  apt  to 
frighten  the  child,  than  the  other. 

Salivary  Fistule. 

Fistules  of  the  salivary  ducts  may  be  upon  the  inside  or  upon  the  out- 
side of  the  mouth.  If  the  abnormal  opening  is  in  the  oral  cavity  itself, 
it  requires  no  treatment.  If,  ho^Yever,  the  opening  is  so  placed  that  the 
saliva  escapes  upon  the  external  surface  of  the  face,  it  is  necessary  to 
operate  in  order  to  turn  the  current  into  the  mouth.  Salivary  fistules 
are  due  to  wounds,  to  abscesses,  to  calculi  impacted  in  the  ducts,  or  to 
obstruction  from  inflammation  of  the  ducts.  The  amount  of  saliva  that 
escapes  from  a  salivary  fistule  during  mastication  may  be  as  much  as  a 
drachm  within  a  few  minutes.  The  fluid  can  be  recognized  as  salivary  by 
the  characteristic  test  with  potassium  sulpho-cyanide  and  with  ferric 
chloride.  I  once  saw  a  case  of  inflammation  of  the  parotid  gland  in 
which  a  transudate  appeared  upon  the  surface  of  the  cheek  which  seemed 
to  be  saliva.  This  local  escape  of  fluid  in  drops  like  sweat  was  lessened 
by  passing  a  probe  into  the  duct  from  the  mouth,  and  relieving  the  ob- 
struction. Unfortunately,  the  patient  passed  out  of  my  hands  before  I 
was  able  to  make  a  test  to  prove  that  the  fluid  upon  the  cheek  was  really 
saliva. 

The  treatment  of  salivary  fistule  must  begin  with  removal  of  the  cal- 
culi or  other  causative  influence.  A  new  opening  must  then  be  made 
from  the  mouth  into  the  duct  behind  the  site  of  the  external  opening. 
This  can  be  done  by  inserting  a  probe  into  the  external  orifice,  passing  it 
along  the  duct  upward  toward  the  gland  and  making  its  point  push  up 
the  mucous  membrane  in  the  mouth.  An  incision  can  then  be  made 
upon  the  point  of  the  probe  and  a  comparatively  large  opening  made 
from  the  duct  into  the  mouth  so  that  the  saliva  will  flow  into  the  buccal 
cavity.  This  new  orifice  must  be  kept  open  by  means  of  daily  insertions 
of  a  probe  from  within  the  mouth.  When  the  internal  opening  has  been 
permanently  established  the  external  fistule  will  soon  heal ;  if  not,  this 
may  be  accomplished  by  the  application  of  caustics,  or  the  orifice  can  be 
closed  by  a  plastic  operation. 

Reteo-pharyxgeal  Abscess. 

Eetro-pharyngeal  abscess  is  a  collection  of  pus  between  the  posterior 
wall  of  the  pharynx  and  the  anterior  surface  of  the  vertebral  bodies  in 
the  cervical  region.  It  is  not  unusual  in  adults,  but  occurs  especially 
in  children  of  unhealthy  constitution.  It  may  result  from  caries  of  the 
cervical  vertebrae,  from  suppuration  of  the  lymphatic  glands  behind  the 
pharynx,  or  from  suppuration  in  some  neighboring  region  burrowing 
behind  the  constrictor  muscles  of  the  pharynx.  At  other  times,  however, 
its  cause  is  not  appai^ent.  Acute  abscess  is  necessarily  more  dangerous 
and  more  rapid  in  its  course  than  a  chronic  tuberculous  collection  of 
puriform  matter  in  this  locality.  The  difiiculty  in  breathing  and  swal- 
lowing associated  with  a  soft,  fluctuating  swelling  at  the  back  of  the 
pharynx  makes  the  diagnosis  evident.  The  abscess  is  not  always  in  the 
middle  line  and  may  give  rise  to  some  stiffness  of  the  neck  due  to  an 
attempt  on  the  part  of  the  muscles  to  fix  the  vertebral  articulation  and 
prevent  pam.     In  the  event  of  spontaneous  evacuation  of  the  abscess 


564  DISEASES    OF    THE    MOUTH. 

there  is  danger  of  the  quantity  of  pus  being  large  enough  to  suffocate 
the  patient  from  its  entrance  into  the  larynx.  At  other  times  the  con- 
tents of  the  abscess  cavity  pass  into  the  stomach  or  are  spat  out.  In 
rare  cases  the  pus  burrows  into  the  posterior  mediastinum  or  along  the 
muscle  sheaths  and  fascial  spaces  of  the  neck.  Early  and  free  evacuation 
of  the  ]His  is  the  essential  treatment.  It  is  accomplished  by  making  a 
vertical  incision  through  the  posterior  pharyngeal  wall  with  the  patient's 
mouth  wide  open,  and  in  getting  rid  of  the  pus,  which  is  often  very  large 
in  amount,  so  as  to  obviate  the  possibility  of  the  patient  drowning.  It 
may  be  wise  to  evacuate  the  major  portion  of  the  pus  by  means  of  a 
trocar  and  canula  in  order  that  the  gush  of  fluid  may  not  asphyxiate  the 
j)atient  by  getting  into  the  larynx.  Subsequently  the  cavity  must  be 
freely  opened  with  a  knife.  Astringent  and  disinfectant  washes  should 
thereafter  be  used. 

Diseases  of  the  (Esophagus, 

Wounds  of  the  oesophagus,  if  external,  are  usually  indicated  by  the 
esca])e  of  food  from  the  opening.  Deglutition  is  accompanied  by  pain, 
and  emphysema  of  the  cellular  tissues  of  the  neck  may  occur  as  a  sec- 
ondary symptom. 

Kupture  of  the  oesophagus  may  occur,  though  rarely,  as  a  result  of 
violent  vomiting ;  and  more  fre(]uently  as  a  sequence  of  stricture  or 
malignant  disease  which  has  caused  softening  and  thinning  of  the  coats. 
Feeding  with  liquids  introduced  by  means  of  a  tube  passed  through  the 
injured  gullet  is  necessary  in  these  cases  if  nutrition  is  not  kept  up  by 
means  of  rectal  injections.  External  wounds  should  be  sutured  by  means 
of  stitches  passed  through  the  o?sophageal  wall,  and  j)rovision  for  drainage 
externally  should  be  made  because  of  the  dangers  of  pus  collection  in  the 
deep  tissues  of  the  neck.  Such  retained  pus  might  very  readily  be  the 
cause  of  mediastinal  abscess  or  pleural  inflammation. 

Foreign  Bodies  ix  the  Oesophagus. 

Foreign  substances  swallowed  may  ])e  caught  in  the  pharynx  or  esoph- 
agus instead  of  passing  into  the  stomach.  Dental  plates  and  artificial 
teeth  are  not  infrequently  thus  swallowed,  and  food  sometimes  becomes 
impacted  in  the  esophagus,  giving  rise  to  trouble.  Very  rarely  fruit 
stones  and  substances  which  have  previously  entered  the  stomach  have 
become  impacted  in  the  oesophagus  during  vomiting.  Bullets  and  other 
missiles  may  enter  the  oesophagus  through  external  wounds  in  the  neck 
and  throat.  Persons  of  hysterical  temperament  sometimes  imagine  that 
foreign  bodies  are  lodged  in  the  gullet  when  no  such  condition  exists. 

Sharp  pieces  of  bone  may,  during  their  passage  through  the  gullet, 
scrape  the  mucous  membrane  and  cause  irritation,  thus  giving  the  patient 
the  sensation  of  a  foreign  substance  impacted  in  the  canal  after  the  vul- 
ne  rating  body  has  actually  passed  into  the  stomach. 

Symptoms. — A  comparatively  large  foreign  body,  lodged  in  the  upper 
en  d  of  the  oesophagus  or  in  the  lower  portion  of  the  pharynx,  causes  a  feel- 
in  g  of  sufl^ocation,  violent  paroxysms  of  dyspucea  on  attempting  to  swallow, 
re  peated  and  vigorous  efforts  at  deglutition,  retching,  spitting  of  saliva,  pos- 
si  bly  mixed  with  blood,  bulging  of  the  eyes,  and  great  anxiety  on  the  part 
of    the  patient,  accompanied  with  sweating  and  prostration.     Pressure  on 


FOKEIGX    BODIES    IN    THE    (ESOPHAGUS.  565 

the  larynx  by,  or  a  spasmodic  condition  of  the  glottis  produced  by  irrita- 
tion from,  a  foreign  body  may  cause  asphyxia  and  death.  Loss  of  voice, 
dysphagia,  and  pain  are  also  symptoms.  The  combination  of  symptoms 
seen  varies  with  the  size  and  character  of  the  impacted  body.  Small  and 
sharp  foreign  substances  will  give  rise  perhaps  to  difficulty  of  respiration 
without  much  actual  interference  with  swallowing,  but  are  apt  to  be 
accompanied  with  blood  expectoration.  The  position  of  the  bodv  also 
causes  change  in  the  combination  of  symptoms.  It  is  possible  in  some 
cases  to  feel  the  obstructing  substance  by  thrusting  the  finger  into  the 
back  part  of  the  fauces  and  down  the  pharynx,  or  by  palpation  of  the 
throat  externally.  Auscultation  of  the  oesophagus  by  means  of  the  stetho- 
scope, placed  upon  the  exterior  of  the  neck,  sometimes  gives  aid  in  diag- 
nosis, because  fluids  or  other  food  swallowed  are  arrested  or  diverted  in 
their  course  by  the  impacted  substance,  and  therefore  produce  sounds 
which  can  be  distinctly  heard  through  the  stethoscope. 

Inflammation  of  the  oesophagus  followed  by  ulceration,  perforation,  or 
abscess,  may  result  from  prolonged  retention  of  a  foreign  body  ;  and  cica- 
tricial contraction  due  to  such  inflammatory  processes  may  cause  stricture 
of  the  oesophagus.  Secondary  to  this  stricture,  dilatation  above  the  point 
of  stricture  and  contraction  of  the  normal  tube  below  may  supervene. 
Perforation  from  a  sharp  foreign  body  or  from  abscess  may  involve  the 
pericardium,  the  heart,  the  trachea,  the  pleura,  the  mediastinum,  or  the 
aorta.  Such  secondary  lesions  are  more  apt  to  occur  and  prove  fatal 
when  the  foreign  substance  is  lodged  low  down  in  the  oesophagus.  The 
presence  of  a  foreign  body  in  the  gullet  may  often  be  proved  by  carefully 
passing  into  the  oesophagus  a  bougie  or  probang,  which  consists  of  an 
olive-shaped  tip  attached  to  a  long,  flexible  stem.  Such  a  bougie  may 
push  small  foreign  bodies  before  it  into  the  stomach,  thereby  relieving 
the  existing  condition.  It  may,  however,  pass  by  a  small  bone  or  similar  ■ 
object  without  dislodging  it,  and  without  giving  the  sensation  of  having 
passed  an  obstruction. 

Treatment. — Masses  of  food  and  foreign  bodies  of  moderate  size  may- 
be carefully  pushed  into  the  stomach  by  the  oesophageal  bougie.  This 
operation  should  be  very  carefully  attempted  lest  the  oesophagus  be 
ruptured,  or  the  mucous  membrane  scraped  loose.  Substances  lodged  in 
the  upper  portion  of  the  gullet  may  be  extracted  through  the  mouth  by 
the  finger  of  the  surgeon  or  by  curved  forceps.  Several  forms  of  instru- 
ments to  draw  out  coins  and  similar  substances  from  the  lower  part  of  the 
oesophagus  have  been  constructed.  A  very  good  method  is  to  fasten  a 
dry  piece  of  a  sponge  on  to  the  end  of  a  rod  of  whalebone  and  pass  this 
beyond  the  obstruction.  The  sponge,  after  becoming  swollen  by  the  fluids 
of  the  oesophagus,  fills  the  calibre  of  the  tube,  and  on  being  withdrawn 
brings  up  the  obstructing  substance.  A  somewhat  similar  instrument  is 
made  of  horse-hair,  which  after  its  introduction  and  passage  beneath  the 
obstruction  is  distended  until  it  fills  the  tube.  Its  withdrawal  carries  the 
offending  substances  upward  into  the  mouth. 

Vomiting  may  be  induced  by  hypodermic  injections  of  apomorphia 
(gr.  Y2  to  S^-  tV)'  or  by  the  administration  of  emetics  by  the  stomach,  to 
cause  ejection  of  the  body  in  the  oesophagus.  Inversion  of  the  patient's 
body  has  sometimes  been  successful  in  causing  expulsion  of  the  offending 
substance.  There  is,  however,  some  danger  in  this  procedure  of  causing 
asphyxia  from  the  foreign  substance  becoming  lodged  in  the  upper  por- 
tion of  the  oesophagus  or  at  the  opening  of  the  glottis.  Where  the  symp- 
toms of  dyspnoea  are  marked,  either  before  the  attempt  at  removal  or 


566  DISEASES    OF    THE    MOUTH. 

during  such  effort,  tracheotomy  should  be  performed  as  a  preliminary 
precaution. 

If  the  methods  described  are  ineffectual  in  relieving  the  patient's  con- 
dition it  then  becomes  neccf^sary  to  open  the  oesophagus.  This  o])eration 
is  called  oesophagotomy.  If  the  operation  is  done  high  up  in  the  throat 
the  name  pharyngotomy  is  applied.  As  it  is  only  possible  to  open  the 
food  tract  in  the  upper  portion  of  the  neck,  it  is  probable  that  what  many 
operators  call  wsopbagotomy  is  actually  pharyngotomy.  External  o?soph- 
agotomv  or  pharyngotomy  is  usually  performed  on  the  left  side  of  the 
neck,  because  the  (esophagus  is  located  a  little  to  the  left  of  the  median 
line.  If,  however,  the  body  to  be  extracted  is  more  prominent  on  the 
right  side,  there  is  no  objection  to  making  the  incision  on  that  a:<pect.  It 
is  only  necessary  to  describe  left-sided  wsophagotomy,  since  that  upon  the 
right  side  is  done  in  a  similar  manner. 

During  the  operation  the  head  should  be  turned  a  little  to  the  right. 
An  incision  parallel  to  the  anterior  border  of  the  sterno-cleido-mastoid 
muscle  should  be  made,  beginning  on  a  level  with  the  upper  border  of  the 
thyroid  cartilage  and  extending  downward  toward  the  sternum  for  four 
or  five  inches.  This  incision  should  be  carried  through  the  tissue  between 
the  sheath  of  the  carotid  artery  and  the  sterno-hyoid  and  the  sterno-thy- 
roid  muscles.  The  thyroid  body  and  trachea  should  be  pushed  toward 
the  middle  line  and  the  sheath  of  the  carotid  vessels  drawn  outward.  In 
this  space  will  be  seen  the  omo-hyoid  muscle  which  may  be  drawn  aside 
and  divided.  Care  should  be  taken  to  avoid  the  inferior  thyroid  artery, 
and  also  the  recurrent  laryngeal  nerve.  The  latter  structure  lies  in  the 
groove  between  the  trachea  and  the  oesophagus.  When  the  gullet  has 
been  exposed  at  the  bottom  of  the  wound,  it  is  well,  if  the  foreign  body 
does  not  make  a  projection,  to  pass  a  bougie  with  a  large  tip  through  the 
mouth,  in  order  that  the  gullet  wall  may  be  pushed  up  toward  the  surface 
and  be  made  easily  accessible  for  incision.  A  silk  ligature  may  be  passed 
through  the  cesophageal  tissues  by  means  of  a  curved  needle,  in  order  to 
give  the  surgeon  control  and  to  enable  him  to  lift  the  wall  toward  the 
external  wound.  A  small  incision  is  next  made  into  the  oesophagus  and 
an  exploratory  finger  passed  into  the  opening,  which  is  subsequently  en- 
larged in  a  longitudinal  direction  if  necessary.  The  foreign  body  is  then 
extracted  with  forceps,  the  oesophageal  wound  is  closed  with  sutures,  and 
provision  made  for  drainage  of  the  external  wound,  the  edges  of  which 
may  be  united  by  buried  and  superficial  sutures. 


Tumors  of  the  CEsophagus. 

PATHOLOfiY. — Growths  of  benign  character  are  quite  rare  in  the 
oesophagus,  but  primary  malignant  disease  in  this  locality  is  not  infre- 
quent. Of  the  forms  of  tumor  epithelioma  is  the  most  common,  and  it 
usually  attacks  the  oesophageal  tube  either  at  the  upper  or  lower  extrem- 
ity. The  affection  is  one  occurring  late  in  life,  and  more  frequently,  it 
would  seem,  in  man  than  in  woman.  Involvement  of  the  surrounding 
glands  and  tissues  is  quite  common  and  ulceration  of  the  growth  usual. 
The  disease  has  a  rather  rapid  course  toward  death,  its  average  duration 
being  from  four  to  sixteen  months.  The  fatal  issue  occurs  fbjm  hemor- 
rhage ;  from  starvation,  the  result  of  the  contraction  caused  by  the  growth 
preventing  the  administration  of  food  ;  from  asphyxia,  due  to  pressure  on 


STRICTURE    OF    THE    (ESOPHAGUS.  567 

the  trachea  and  the  primary  bronchi,  and  from  secondary  lung  condi- 
tions. 

Symptoms. — The  symptoms  are  like  those  of  non-malignant  stricture 
hereafter  to  be  described,  and  consist  of  jDain,  difficulty  in  swallowing, 
regurgitation  of  food,  offensive  breath,  delayed  digestion,  constipation, 
inanition,  and  great  debility.  The  gullet  is  apt  to  be  dilated  above  the 
site  of  the  epitheliomatous  stricture,  and  may  become  perforated  by 
ulcers  in  the  neighborhood  of  the  malignant  growth.  SymjDtoms  arising 
from  pressure  upon  the  neighboring  viscera  may  be  prominent,  and  in 
some  cases  there  is  external  evidence  of  tumor. 

Diagnosis. — The  early  stages  of  malignant  disease  of  the  oesophagus 
may  resemble  hysterical  stricture.  A  tumor  outside  of  the  oesophagus 
pressing  the  wall  inward  will  give  similar  symptoms,  and  at  times  render 
diagnosis  of  the  true  condition  difficult.  Exploration  of  the  cesophagus 
with  a  flexible  bougie,  such  as  was  described  in  the  discussion  of  foreign 
bodies  lodged  in  the  oesophagus,  will  prove  the  existence  of  a  growth  of 
some  sort  if  the  contraction  made  by  it  is  at  all  conspicuous.  It  may  be 
possible  to  differentiate  the  histological  elements  and  to  characterize  the 
nature  of  the  growth  by  microscopical  examination  of  the  tissue  scraped 
off  by  the  bougie. 

Fibroid  growths  of  the  oesophagus  give  the  impression  of  a  smooth 
surface  when  touched  with  the  bougie,  are  much  more  resistant  than  a 
malignant  tumor,  and  do  not  bleed.  Hemorrhage  occurring  after  careful 
manipulation  suggests  malignant  tumor,  as  does,  of  course,  the  existence 
of  a  purulent,  bloody  discharge. 

Treatment. — If  the  disease  is  situated  in  the  upper  portion  of  the 
tube,  oesophagotomy  may  permit  the  removal  of  the  tumor  if  small,  or 
oesophagostomy,  which  is  the  formation  of  a  permanent  opening  in  the 
oesophagus,  will  establish  an  opening  by  which  food  can  be  administered. 
Removal  of  such  growths  by  opening  the  gullet  is  only  justifiable  when 
the  disease  is  limited.  In  other  cases  a  small  bougie  may  be  passed  every 
two  or  three  days  in  the  effort  to  keep  the  tube  open  and  to  allow  the  food 
to  be  administered  by  the  normal  channel.  If  the  operations  suggested 
are  not  deemed  advisable  the  performance  of  gastrostomy  will  permit 
feeding  by  fistule  so  made  in  the  stomach.  Gastrostomy  is  often  delayed 
too  long  until  the  patient  is  too  weak  to  enjoy  long  the  benefit  of  the 
operation.  In  the  event  of  these  operative  measures  being  impossible, 
the  surgeon  can  do  nothing  but  render  death  easy  by  palliating  measures. 


Stricture  of  the  (Esophagus. 

Pathology. — Diminution  in  the  calibre  of  the  oesophagus  may  be  due 
to  organic  changes  and  contractions  resulting  from  malignant  disease 
and  the  other  conditions  which  have  been  mentioned,  and  to  cicatricial 
contraction  following  inflammation  of  the  oesophageal  coats.  Swallowing 
hot  liquids  or  strong  acids  and  alkalies  with  suicidal  intent,  or  by  acci- 
dent, are  frequent  causes  of  such  coarctations.  Syphilis,  tuberculosis  of 
the  mucous  and  submucous  tissues  of  the  gullet,  and  wounds  due  to 
foreign  bodies  may,  in  a  similar  manner,  lead  to  obstruction  in  the 
oesophagus.  So,  also,  aneurism,  foreign  bodies  in  the  trachea,  and 
abscesses  or  tumors  outside  the  oesophagus  may,  by  pressure  upon  its 
walls,  cause  diminution  of  its  calibre.  The  condition  called  oesophagis- 
nius,  or  spasm  of  the  muscular  coat  of  the  oesophagus,  which  occurs  at 


568  DISEASES    OF    THE    MOUTH, 

times  in  hysteria,  gives  rise  to  symptoms  »)f  stricture.  A  bougie  can, 
however,  be  readily  piussed  through  the  contracted  portion,  and  meets  in  its 
passage  with  no  percejjtible  resistance.  Indeed,  the  successful  introduc- 
tion of  such  a  bougie  will  often  convince  the  patient  that  no  danger  from 
obstruction  exists,  and  be  thus  the  means  of  curing  the  symptom.s.  Aus- 
cultation with  a  stethoscope,  placed  over  the  oesophagus  on  the  left  side 
of  the  neck,  is  said  to  give  information  that  the  stricture  is  spasmodic 
and  not  an  organic  one.  In  the  former  case  food  which  has  been  swal- 
lowed is  regurgitated  immediately;  but  in  the  case  of  true  stricture 
regurgitation  of  ingested  materials  is  more  slow.  Qilsophagismus,  more- 
over, is  intermittent  and  not  constant.  The  medical  treatment  of  this 
hysterical  affection  consists  in  curing  the  coincident  nervous  symptoms. 
Fibroid  or  cicatricial  strictures  usually  take  place  in  the  upper  part  of 
the  oesophagus  or  in  the  pharynx.  The  contraction  may  be  due  to  a 
puckering  of  the  inner  coats  of  the  tube  at  the  site  of  the  scar,  it  may 
consist  in  a  crescentic  ridge  extending  partly  around  the  tube  on  its 
internal  surface,  or  it  may  be  a  cicatricial  ring  involving  the  entire  cir- 
cumference of  the  -gullet.  Abscess  about  the  injured  portion  may  be 
present. 

Symptoms. — Difficulty  in  swallowing  solid  food  is  one  of  the  early 
symptoms  of  (esophageal  stricture.  If  the  contraction  increases,  degluti- 
tion of  liquid  foods  soon  becomes  difficult.  Regurgitation  of  food  may 
take  place  after  it  has  reached  this  stage,  and  may  be  slight,  or  amount 
to  actual  ceso])hageal  vomiting.  The  time  at  which  regurgitation  or 
vomiting  takes  place,  after  the  attempt  at  sw^allowing  food,  gives  an  ap- 
proximate idea  of  the  position  of  the  disease.  The  food  when  ejected 
may  be  more  or  less  putrid,  and  mixed  with  blood  or  smeared  with  mucus. 
A  discharge  from  the  oesophagus,  having  a  coffee-color,  is  symptomatic  of 
malignant  disease.  The  pain  is  usually  slight  at  first,  unless  there  is  acute 
inflammation  accompanying  the  stricture ;  severe  pain  may  then  be  ex- 
perienced. It  may  radiate  to  the  shoulders  and  to  the  epigastrium.  The 
location  of  the  most  severe  and  constant  pain  may  indicate  the  seat  of 
stricture,  which  may  be  more  or  less  certainly  ascertained  by  the  sense  of 
stoppage  in  the  food-tract  when  the  patient  endeavors  to  swallow  nutri- 
ment. The  use  of  the  stethoscope  may  give  the  surgeon  an  idea  of  the 
position  of  the  disease,  because  he  may  thereby  learn  the  point  at  which 
food  stops  in  swallowing,  or  the  point  through  which  the  food  passes  with 
difficulty.  Palpation  of  the  throat  may  at  times  reveal  the  mass  which 
has  caused  the  obstruction.  The  lodgement  of  food  which  takes  place 
above  the  contracted  portion  causes  dilatation  and  hypertrophy  of  the 
wall  of  the  gullet.  Great  debility  and  emaciation  are  later  symptoms  of 
the  disease  and  are  particularly  slow  in  their  progress  when  the  stricture 
is  a  cicatricial  one  rather  than  a  malignant  one. 

The  passage  of  an  oesophageal  bougie  will  give  the  surgeon  information 
as  to  the  distance  from  the  front  teeth,  and  the  length,  number,  and  calibre 
of  the  contracted  portions. 

Treatment. — The  treatment  of  oesophageal  stricture  consists  in  giving 
rest  to  the  diseased  organ,  in  nourishing  the  patient,  and  in  dilating  the 
contracted  tube.  Rest  is  obtained  by  keeping  up  the  patient's  nutrition 
through  rectal  injections  of  milk,  broth,  and  other  nutritious  articles. 
This  procedure  is  of  special  value  if  there  is  great  sensitiveness  of  the 
oesophagus,  since  eftbrts  at  alimentation  through  the  oesophagus  then 
cause  great  distress  and  depression  of  the  patient. 

Dilatation  of  the  contracted  and  contracting  oesophagus  is  accomplished 


STRICTURE    OP    THE    (ESOPHAGUS.  569 

by  the  introduction  of  bougies  with  conical  tips,  the  size  of  which  is 
gradually  increased.  The  bougie  should  not  be  passed  oftener,  as  a  rule, 
than  once  in  three  days,  but  at  one  sitting  two  or  three  increasing  sizes 
may  be  successively  introduced,  each  of  which  may  be  left  in  position 
about  ten  minutes.  Such  intermittent  dilatation  should  be  made  in  a 
gradual  manner,  since  attempt  to  pass  a  large  bougie  after  the  passage 
of  a  much  smaller  one,  is  liable  to  cause  laceration  of  the  tissues.  Rapid 
dilatation  is  not  safe,  even  if  it  were  possible  to  substitute  it  for  slow 
intermittent  dilatation,  which  has  just  been  recommended.  Continuous 
dilatation  can  be  accomplished  by  the  introduction  and  leaving  in  position 
of  tubes  large  enough  to  stretch  the  strictured  portion  slightly.  Through 
this  tube,  which  may  be  allowed  to  remain  for  three  or  four  days,  food 
can  be  introduced.  At  the  end  of  this  time  the  tube  should  be  taken 
out  to  be  cleaned,  and  should  then  be  reinserted  or  succeeded  by  a  tube 
slightly  larger. 

There  are  other  oesophageal  bougies  which,  after  being  placed  in  posi- 
tion through  the  stricture,  may  be  dilated  with  air  or  water.  Again, 
there  are  dilators  which  can  be  spread,  after  their  introduction,  in  much 
the  same  manner  as  instruments  used  for  dilating  strictures  of  the  urethra. 

Internal  oesophagotomy,  or  division  of  the  stricture,  by  a  sharp  blade 
concealed  in  a  sheath  during  its  introduction  through  the  mouth  and 
pharynx  is  dangerous  because  of  the  liability  of  dividing  the  wall  of  the 
gullet  as  well  as  the  stricture.  It  is  good  practice  in  certain  cases  to  per- 
form external  oesophagotomy  just  above  or  just  below  the  stricture,  and 
then  to  make  an  internal  oesophagotomy. 

External  cesophagotomy,  or  opening  of  the  oesophageal  tube  from  the 
exterior  of  the  throat  may  be  useful,  as  has  just  been  stated,  to  gain 
access  to  the  stricture  in  order  that  it  may  be  dilated  or  incised,  and  also 
for  the  purpose  of  obtaining  an  opening  through  which  food  may  be 
passed  into  the  stomach.  In  the  latter  case  the  operation  is  called  oeso- 
phagostomy.  Such  operations,  it  is  evident,  can  only  be  done  when  the 
disease  is  situated  high  in  the  neck  and  gives  room  for  an  external  inci- 
sion above  the  clavicle.  When  the  disease  is  situated  in  the  lower  portion 
of  the  gullet  the  stomach  should  be  opened  through  the  abdominal  wall 
and  a  gastric  fistule  established  for  the  introduction  of  food.  This  ope- 
ration is  called  gastrostomy  or  "  stomach-mouth  "  in  contra-distinction  to 
gastrotomy,  in  which  the  stomach  is  oj)ened  for  the  removal  of  a  foreign 
body  and  immediately  closed. 


Introduction  of  the  (Esophageal  Bougie  or  Stomach-pump  Tube. 

Tubes  or  bougies  may  require  to  be  introduced  into  the  oesophagus 
alone  or  into  the  cavity  of  the  stomach  for  purposes  of  diagnosis,  for  the 
treatment  of  stricture,  for  the  evacuation  of  poisons  which  may  have  en- 
tered the  stomach,  for  washing  out  the  stomach,  and  for  feeding.  It  is 
important,  therefore,  that  the  surgeon  should  be  familiar  with  the  method 
of  using  these  diagnostic  and  therapeutic  instruments.  The  patient 
should  be  seated  with  his  head  thrown  well  back,  in  order  to  bring  the 
mouth  and  the  long  axis  of  the  gullet  in  the  same  line.  The  mouth, 
which  should  be  wide  open,  may  or  may  not  be  prevented  from  closing 
by  means  of  a  gag  between  the  teeth.  This  is  seldom  needed,  except  in 
obstreperous  patients.  The  surgeon,  standing  in  front  of  the  patient, 
should  then  pass  the  instrument,  which  has  previously  been  well  oiled  and 


570  DISEASES    OF    THE    MOUTH. 

warmed,  through  the  mouth  l)ack\var(l  toward  the  jiosterior  wall  of  the 
pharynx.  This  portion  of  the  operation  should  he  done  without  touching 
the  patient's  tongue.  With  his  left  forefinger  the  operator  next  guides 
the  instrument  above  the  epiglottis  and  downward  into  the  upper  portion 
of  the  a?sophagus.  Pressure  slowly  applied  then  pushes  the  instrument 
downward  toward  the  stomach.  If  any  obstruction  is  felt  the  instrument 
should  be  slightly  withdrawn  and  again  gently  pushed  forward.  The 
patient  will  soon  discover  that  he  can  breathe  notwithstanding  the  pres- 
ence of  a  foreign  body  in  the  food-tract,  and  he  will  suti'er  little  or  no 
inconvenience.  Care  must  be  taken,  however,  not  to  push  the  instrument 
into  the  trachea,  which  is  likely  to  occur  if  the  tube  be  a  small  one.  If 
the  surgeon  prefer,  he  may  stand  behind  the  patient  and,  steadying  the 
latter's  head  against  his  chest,  introduce  the  bougie  or  tube  from  this  po- 
sition. In  this  method,  however,  the  surgeon's  forefinger  cannot  be  used 
to  insure  the  slipping  of  the  instrument  over  the  epiglottis.  It  therefore 
requires  a  little  more  dexterity  on  the  part  of  the  surgeon. 

When  the  tube  of  the  stomach-pump  is  thus  introduced  for  washing 
out  the  stomach,  aliout  two  pints  of  warm  water  should  be  allowed  to 
flow  through  the  tube.  This  may  be  done  by  ])ouring  water  into  a  funnel 
attached  to  the  outer  end  of  the  tube,  or  by  attaching  to  this  extremity 
some  form  of  a  pump.  When  the  fluid  is  withdrawn  from  the  stomach 
it  is  wise  not  to  permit  all  to  come  out,  as  the  mucous  membrane  lining 
of  the  stomach  may  be  sucked  into  the  opening  at  the  gastric  extremity 
of  the  tube. 


CHAPTEE    XXI. 

DISEASES  OF  THE  ABDOMEX  AXD  PELVIS. 

The  fcetal  canal  extending  from  the  bladder  to  the  umbilicus  may 
remain  patulous  after  birth.  This  tubular  canal  may  then  permit  the 
discharge  of  small  quantities  of  urine  at  the  umbilicus.  In  rare  instances 
such  an  unobliterated  urachus  has  been  laid  open  in  performing  abdomi- 
nal section  for  the  treatment  of  abdominal  disease.  Cystic  tumor,  abscess, 
and  other  pathological  processes  may  occur  here.  Urinary  calculi  have 
been  found  in  a  patulous  urachus. 

Wounds  of  the  abdomen,  when  fatal,  have  probably  caused  injury  to 
the  solar  plexus,  or  to  some  one  of  the  glandular  or  hollow  viscera  ;  which 
injury  will  be  revealed  by  an  autopsy.  Death  occurring  without  discov- 
able  lesion  is  very  infrequent.  Contusions  or  wounds  of  the  abdominal 
wall  have  no  special  importance  except  when  associated  with  rupture  of 
the  viscera  or  some  other  internal  lesion.  They  are  treated,  when  uncom- 
plicated, as  are  wounds  in  other  regions.  AYhen  there  is  a  probability  of 
visceral  lesion  as  a  complication,  the  necessity  for  abdominal  section  and 
exploration  is  often  imperative. 

Wounds  of  the  abdomen  are  of  extreme  importance,  because  of  the 
probability  of  injury  to  the  contents  of  the  abdomen  and  pelvis.  Gun- 
shot or  stab  wounds  of  the  belly  are  so  liable  to  be  complicated  with 
intestinal  lesions  that  abdominal  section  is  very  often  required,  in  order 
to  secure  the  patient  from  death  by  reason  of  internal  hemorrhage  or 
fecal  extravasation  into  the  peritoneal  cavity.  It  is  often  doubtful 
whether  a  bullet  or  a  cutting  instrument  has  actually  penetrated  the 
intestines,  because  at  times  the  vulneratiug  instrument  does  not  travel  the 
entire  thickness  of  the  wall,  or  is  deflected  by  the  muscular  fascias.  The 
hydrogen  test  of  Senn  consists  in  inflating  the  intestinal  canal  with  hydro- 
gen gas  introduced  through  the  rectum  by  means  of  a  rubber  tube  con- 
nected with  a  reservoir  or  rubber  bag  filled  with  gas.  The  hydrogen 
distends  the  intestinal  canal,  escapes  through  any  perforation  that  has 
been  made  in  it,  and  after  filling  the  peritoneal  sac  escapes  through  the 
external  opening.  Its  presence  at  this  point  is  detected  by  holding  a 
lighted  taper  to  the  wound  when  the  gas,  as  it  escapes,  becomes  ignited. 
Such  ignition  is  a  positive  evidence  of  a  wound  in  the  intestines.  Unfor- 
tunately, however,  the  absence  of  the  escape  of  hydrogen  is  not  positive 
proof  that  no  orifice  exists  in  the  gut. 

If  a  doubt  exists  as  to  the  ji^ropriety  of  opening  the  abdomen  for  the 
purpose  of  discovering  and  repaii'ing  visceral  damage,  it  is  usually  Avise 
to  give  the  patient  the  benefit  of  the  doubt  and  to  operate.  Carefully 
done,  aseptic  abdominal  section  is  almost  free  from  danger,  whereas  intes- 
tinal wounds  have  a  large  death-rate  from  peritonitis.  The  exploratory 
incision  should  be  made  in  the  median  line,  after  which  the  whole  length 
of  the  intestinal  tract  should  be  carefully  examined,  unless  the  wound  in 
the  wall  has  shown  that  the  wounding  of  the  stomach  or  intestine  has 
been  impossible. 


572  DISEASES    OF    THE    ABDOMEN    AND    PELVIS, 


Method  of  Operating  within  the  Abdomen  and  Pelvis. 

Before  describing  the  various  operative  procedures  demanded  liy  abdom- 
inal and  pelvic  diseases  and  injuries,  it  is  necessary  to  discuss  the  general 
method  of  performing  surgical  operations  in  these  cavities.  Fluids  occur- 
ring and  accumulating  in  the  alxlonunal  cavity  as  a  result  of  irritation 
are  very  liable  to  septic  changes.  Therefore,  the  most  absolute  asepsis  is 
important,  since  the  large  absorbent  surface  furnished  by  the  peritoneal 
membrane  makes  the  occurrence  of  septic  processes  in  this  cavity  ex- 
tremely dangerous.  Twisted  silk  is  usually  preferred  for  ligatures  by 
abdominal  surgeons,  while  plaited  silk  or  silkworm-gut  is  ordinarily 
deemed  most  .satisfactory  for  suturing  purposes.  Catgut,  however,  is  avail- 
able. These  and  all  instruments  and  sponges  should  be  rendered  abso- 
lutely sterile.  The  use  of  antiseptic  solutions  within  the  abdominal  cavity 
is  usually  deprecated,  because  of  the  danger  of  these  chemical  solutions 
even  when  weak  causing  undue  irritation.  Experience  has  proved  that 
water  sterilized  by  boiling  does  not  possess  this  disadvantage,  and  of  course 
is  perfectly  safe.  The  frequency  with  which  the  external  wound  has  been 
sutured  when  instruments  and  sponges  have  been  left  in  the  abdomen  is 
sufficient  reason  to  demand  that  all  instruments  and  sponges  shall  be 
counted  before  and  after  operation. 

The  abdominal  incision,  which  should  usually  be  made  in  the  median 
line,  should  be  large  enough  to  permit  good  work.  It  is,  perhaps,  wise 
to  begin  with  a  small  incision,  varying  with  the  character  of  the  operation 
to  be  performed,  and  to  enlarge  it  as  necessity  becomes  evident.  In  opera- 
tions for  appendicitis  and  other  conditions  about  the  csecal  region,  an  inci- 
sion to  the  outer  side  of  the  right  rectus  muscle  is  often  preferable  to  one 
in  the  middle  line. 

Tumors  within  the  abdomen  sometimes  become  adherent  to  the  anterior 
wall,  and  the  incision  will,  therefore,  reach  them  before  the  surgeon  enters 
the  abdominal  cavity.  Such  adhesions  of  the  growth  may  be  suspected  if 
there  is  much  bleeding  from  the  muscular  incision,  or  unusual  pinkne.ss  of 
the  deep  muscular  fascias  and  the  subperitoneal  fat.  In  all  cases,  the 
surgeon  should  be  careful  to  get  within  the  abdominal  cavity  before  work- 
ing along  the  wall  from  the  incision.  If  he  does  not  be  careful  in  this 
regard  he  may  separate  a  large  sheet  of  peritoneum  from  the  inner  surface 
of  the  muscles,  and  think  that  he  is  detaching  an  ovarian  cyst  or  other 
growth  adherent  to  the  internal  surface  of  the  abdominal  wall. 

During  operation  the  intestines  should  be  kept  out  of  the  way  as  much 
as  possible  by  packing  llat,  warm,  aseptic  sponges  around  the  field  of 
operation,  so  as  practically  to  shut  it  out  from  the  rest  of  the  peritoneal 
cavity.  These  sponges  should  be  squeezed  out,  or  substituted  by  clean 
ones  when  they  become  saturated  with  blood,  serous  fluid,  or  pus.  If  it 
is  necessary  to  allow  the  intestines  to  escape  from  the  cavity  temporarily, 
they  should  be  wrapped  up  in  a  warm,  moi.st,  aseptic  towel,  which  will 
not  allow  particles  of  lint  to  be  detached  from  it. 

The  adhesions  and  attachments  of  morbid  growths  and  diseased  struc- 
tures to  be  removed  should  be  separated  by  means  of  the  finger,  as  the 
tearing  thus  performed  is  not  very  liable  to  be  followed  by  bleeding.  The 
attachments,  if  vascular,  should  be  cut  only  after  firm  ligation,  or  com- 
pression of  the  stump  by  hreraostatic  forceps.  Points  likely  to  bleed  must 
be  ligated  before  the  forceps  are  removed. 

By  the  toilet  of  the  peritoneum,  is  meant  the  removal  of  all  blood  and 


OPERATING    WITHIN    THE    ABDOMEN    AND    PELVIS.      573 

other  fluids  by  irrigation  or  by  sponges  which  have  been  pushed  into  the 
pelvic  or  lumbar  fossse.  This  may  require  them  to  be  seized  by  long 
forceps,  so  as  to  give  them  a  sort  of  handle.  If  the  fluid  is  gelatinous  or 
purulent,  it  will  be  necessary  to  wash  out  the  cavity  with  sterilized  water 
of  a  temperature  of  105°,  poured  into  the  cavity  from  an  ordinary  pitcher, 
or  from  the  tube  of  a  fountain  syringe.  By  this  means  any  unrecognized 
bleeding  is  discovered,  because  the  water  returns  stained,  and  shreds  o± 
tissue  or  lymph  are  effectively  removed.  It  is  not  necessary  to  insist  upon 
the  removal  of  all  such  sterilized  water  which  has  been  used  to  flush  the 
cavity,  because  it  is  harmless  and  is  soon  absorbed. 

Whenever  it  is  believed  that  a  purulent  cavity  has  not  been  perfectly 
cleansed,  and  that  purulent  material  remains,  it  becomes  necessary  to  leave 
a  drainage-tube  in  the  wound  at  the  time  of  adjusting  the  sutures.  Healthy 
peritoneum  absorbs  aseptic  fluids  rapidly,  but  a  diseased  peritoneum  does 
so  very  slowly.  In  such  cases,  and  where  there  is  very  great  transudation 
of  fluid  subsequent  to  operation,  Douglas's  pouch  becomes  the  receptacle 
in  which  such  fluids  accumulate ;  and  disastrous  inflammation  is  liable  to 
occur  because  of  the  possibility  of  septic  changes  occurring  there.  Hence 
drainage  is  often  desirable  in  such  cases.  If  the  hemorrhage  has  not  been 
entirely  stopped,  or  bleeding  subsequent  to  the  operation  is  feared,  the 
insertion  of  a  drainage-tube  is  wise.  Any  excess  of  fluid  accumulating 
after  operation  may  then  be  removed  by  introducing  a  long-nozzle  aseptic 
syringe  through  the  tube  at  frequent  intervals.  The  occurrence  of  sec- 
ondary hemorrhage  will  be  indicated  by  the  escape  of  blood  through  the 
drainage-tube,  and  will  thus  be  susceptible  of  prompt  treatment.  These 
circumstances  render  it  probable  that  in  cases  of  doubt  as  to  the  necessity 
of  drainage,  the  sui'geon  had  better  use  a  drainage-tube,  since,  if  the  asepsis 
is  perfect,  it  can  scarcely  do  harm.  In  cases  where  the  operation  has  been 
simple  and  uncomplicated,  however,  and  when  no  pus  has  previously 
existed,  complete  closure  of  the  wound  without  drainage  is  the  proper 
procedure.     A  straight  or  curved  glass  tube,  having  a  calibre  of  about  a 

Fig.  366. 


Glass  abdominal  drainas!e-tube. 

half  inch,  with  an  opening  in  its  abdominal  extremity,  and  with  a  ridge 
or  shoulder  at  its  cutaneous  end,  is  the  proper  sort  of  tube  to  be  employed. 
A  piece  of  rubber  tubing  will  answer  the  purpose  nearly  as  well.  It  is 
rather  objectionable  to  have  lateral  openings  in  the  tube  near  its  outer 
end,  because  fluids  entering  the  tube  at  its  lower  end  may  escape  from 
these  lateral  openings  and  becoming  septic  if  the  dressings  are  imperfect, 
infect  the  wound  in  the  abdominal  wall.  The  tube,  as  a  rule,  should  be 
about  six  inches  long,  and  descend  into  the  pelvis  or  one  of  the  lumbar 
fossae.  Under  rare  circumstances  it  becomes  necessary  to  introduce  two 
or  three  tubes,  in  order  to  allow  free  drainage  or  irrigation  in  distinct 
regions  of  the  abdomen. 

Suction  with  a  syringe  will  remove  fluids  which  accrue  in  the  tube. 
The  escape  may  be  so  great  as  to  require  this  cleansing  of  the  tube  every 


574  DISEASES    OF    THE    ABDOMEN    AND    PELVIS. 

few  hours,  or  even  oflener.  Tlie  insertion  of  a  small  quantity  of  absorbent 
cotton,  twisted  into  a  rope  and  put  into  the  tube,  will  increase  the  drainage 
and  remove  the  Huid  by  capillarity.  A  sort  of  wick  of  absorbent  gauze  will 
be  efficacious  in  the  same  way.  It  is  essential  that  the  abdominal  cavity  be 
kept  dry  and  free  from  Huid  when  oozing  of  blood  is  going  on  after  closure 
of  the  wound,  because  moisture  seems  to  encourage  the  flow  of  blood. 
It  goes  without  saying,  of  course,  that  all  recognizable  bleeding  points 
should  be  secured  by  ligatures,  or  by  the  application  of  the  cautery,  before 
the  abdomen  is  closed. 

Fig.  367. 


Tail's  syringe. 

The  abdominal  wound  should  be  brought  together  by  sutures  of  silk, 
catgut,  wormgut,  or  wire,  carried  through  the  entire  thickness  of  the 
wall,  including  the  peritoneum.  Interrupted  sutures  should  be  used. 
If  a  drainage-tube  is  to  be  employed,  the  suture  at  the  point  where  the 
tube  comes  out  should  not  be  tied,  so  that  when,  at  the  end  of  the  second 
or  third  day,  the  tube  is  removed,  the  wound  may  be  brought  together  by 
this  suture  and  the  pain  of  using  a  needle  avoided.  An  ordinary  gauze 
dressing,  either  aseptic  or  antiseptic,  is  then  applied,  and  a  many-tailed 
flannel  bandage  carried  around  the  loins,  and  secured  in  such  a  way  as  to 
make  equable  pressure  upon  the  abdominal  wall.  If  a  drainage-tube  is 
used,  its  external  end  should  be  thrust  through  a  small  opening  made  in 
the  centre  of  a  piece  of  strong  rubber  tissue  about  eight  inches  square.  A 
ligature  should  then  be  thrown  around  the  tube  in  such  a  way  as  to  tie 
the  rubber  material  close  to  the  tube.  This  is  to  prevent  the  possibility 
of  fluid  escaping  from  the  tube  and  running  down  its  outside  and  coming 
in  contact  with  the  wound.  By  placing  a  mass  of  absorbent  cotton,  or  a 
sponge,  over  the  orifice  of  the  tube,  and  folding  the  edges  of  the  rubber 
dam  around  it,  a  little  bag  is  formed  in  which  the  escaping  fluid  is  retained, 
and  thus  prevented  from  coming  in  contact  with  the  wound,  which,  there- 
fore, heals  by  first  intention.  This  rubber  bag,  as  it  practically  is,  can  be 
opened  several  times  a  day,  if  necessary,  to  suck  out  the  tube  with  a 
syringe,  and  to  remove  the  saturated  cotton  or  sponge.  This  can  all  be 
done  without  disturbing  the  main  dressing. 

The  after-treatment  of  cases  of  abdominal  operation  is  very  simple, 
unless  some  complication  arises.  Beef  tea,  thin  arrowroot  or  oatmeal 
gruel,  given  in  small  quantities  about  every  two  hours,  is  probably  the 
best  food.  Milk  is  believed  to  be  improper  food,  because  of  its  supposed 
tendency  to  induce  flatulency.  As  a  rule,  it  is  well  to  give  no  food  for  the 
first  twenty-four  hours.  During  this  time  it  is  usual  to  administer  only 
small  amounts  of  water.     Most  foods  are  perhaps  better  digested  if  pepto- 


OPERATING    WITHIN    THE    ABDOMEN    AND    PELVIS,      575 

nized.  Thirst  is  relieved  by  rather  copious  injections  of  water  into  the  rectum, 
which  is  better,  perhaps,  than  swallowing  large  draughts  of  water  by  the 
mouth  or  sucking  ice.  Very  frequently  the  catheter  will  not  be  demanded  ; 
occasionally,  however,  it  is  required.  Morphia  should  not  be  given  unless 
absolutely  required,  and  then  in  small  amounts.  It  may  sometimes  be 
administered  hypodermically.  It,  and  all  opiates,  tend  to  constipate  the 
patient,  to  disturb  digestion,  and  to  mask  symptoms  of  danger.  Vomiting 
is  liable  to  occur  within  the  first  twenty-four  hours  as  a  result  of  the 
anaesthesia.  If  it  exists,  or  begins  on  the  third  or  fourth  day,  it  is  prob- 
able that  it  is  caused  by  incipient  inflammation  of  the  peritoneum. 

The  dangers  to  be  feared  in  abdominal  cases  are  protracted  vomiting, 
tympanites,  and  peritonitis.  The  two  former  are  often  associated,  and  are 
usually  indicative  of  incipient  peritonitis.  Vomiting  is  often  an  efibrt  to 
get  rid  of  flatus,  and  is  therefore  to  be  looked  upon  as  salutary.  Copious 
vomiting  induced  by  the  administration  of  warm  water  as  an  emetic  will 
often  aid  in  the  eructation  of  a  large  amount  of  wind,  and  be  of  other 
service.  If  the  distention  of  the  abdomen  from  flatus  is  great,  it  should 
be  relieved  by  allowing  the  patient  to  lie  upon  his  side,  or  by  the  intro- 
duction of  a  tube  in  the  rectum.  A  large  rubber  catheter,  or  the  tube  of 
a  stomach  pump  makes  a  good  rectal  tube  for  this  purpose,  and  may  be 
left  in  the  rectum  for  many  hours  at  a  time. 

Incipient  peritonitis,  as  has  been  suggested  before,  is  liable  to  cause 
vomiting  and  distention  of  the  abdomen.  Relief  of  the  vomiting  and  of 
this  tympanites  will  frequently  be  followed  by  rapid  improvement  of  the 
patient.  It  is  probable,  therefore,  that  the  early  removal  of  these  symp- 
toms prevents  the  occurrence  of  destructive  peritonitis.  The  administra- 
tion of  a  saline  cathartic,  such  as  Epsom  salt,  Rochelle  salt,  or  Seidlitz 
powder,  so  as  to  produce  free  evacuation  of  the  bowels,  will  often  give 
this  desirable  result.  The  administration  of  opium  in  such  cases  of  oper- 
ative peritonitis  is  decidedly  harmful  and  should  not  be  adopted.  Turpen- 
tine injected  into  the  rectum,  about  half  an  ounce  of  turpentine  to  the 
quart  of  soap-suds,  will  be  of  service  in  similar  manner  by  promoting  the 
discharge  of  gas  and  the  evacuation  of  the  intestinal  contents. 

The  purgative  treatment  of  incipient  peritonitis  probably  owes  its  value 
to  the  prevention  of  distention  and  to  the  draining  of  the  abdominal 
organs  of  their  serum.  Carminatives,  such  as  ether  and  peppermint,  can 
be  administered  by  the  stomach  as  adjuvants,  but  will  not  very  often  be 
required.  When  vomiting  is  marked,  nutrition  should  be  kept  up  by 
rectal  feeding,  which  is  best  done  by  the  use  of  peptonized  foods  in  a 
diluted  state. 

Traumatic  Per  Hon  it  is. 

Peritonitis,  occurring  after  operations  done  in  the  manner  just  described 
is  rare.  If  the  early  sj^mptoms  of  peritonitis  are  met  by  the  administra- 
tion of  saline  purgatives  and  if  abstinence  from  the  use  of  opium  is  en- 
forced, it  is  probable  that  active  peritoneal  inflammation  will  not  often 
occur.  Should  it  take  place  it  demands  active  treatment,  such  as  opening 
of  the  abdomen  in  order  to  wash  out  and  drain  from  the  pelvis  the  accu- 
mulated fluid  which  has  become  septic.  The  continued  use  of  salines  in 
laxative  doses  and  the  avoidance  of  tympany  are  the  essentials  in  the 
medical  management  of  this  disease.  Traumatic  peritonitis  commonly 
follows  wounds  which  have  not  been  at  once  submitted  to  aseptic  or  anti- 
septic treatment.     The  vulnerating  instrument  is  often  a  dirty  one,  and 


57(3  DISEASES    OF    THE    ABDOMEN    AND    PELVIS. 

the  clothing  of  the  patient  and  his  surroundings  may  cause  septic  inflam- 
mation before  he  reaches  the  surgeon's  hands. 

A  circumscribed  peritonitis  occurs,  however,  in  some  cases  both  in 
operative  and  accidental  wounds.  If  there  is  absence  of  septic  infection 
the  lymph  exuded  seals  the  wound  and  healing  rapidly  occurs.  By  such 
an  e.vudation  of  lymph  even  a  septic  peritonitis  is  sometimes  circum- 
scribed and  then  may  not  do  much  harm,  because  the  septic  focus  has 
been  shut  off  from  the  rest  of  the  abdomen  by  the  plastic  exudate.  It  is 
the  diffused  septic  inflammation  of  the  peritoneum,  which  gives  rise  to  a 
large  quantity  of  turbid  serum  or  pus  within  the  peritoneal  cavity,  which 
is  so  fatal. 

The  symptoms  of  traumatic  peritonitis  are  vomiting  and  flatulency  with 
more  or  less  pain  and  rapid  breathing.  It  must  be  recollected  that  pain 
may  be  almost  absent,  however,  and  that  high  temperature  is  often  not 
present.  The  cause  of  the  peritonitis  should  always  be  sought  for,  and 
this  search  will  usually  demand  opening  of  the  abdomen.  Intussuscep- 
tion of  the  intestines,  rupture  or  inflammation  about  the  vermiform  appen- 
dix, or  the  pouring  out  of  pus  into  the  pelvic  cavity  from  a  ruptured, 
suppurating  Fallopian  tube,  will  often  be  found  to  be  causes  of  what  was 
supposed  to  be  traumatic  peritonitis  following  a  slight  injury.  Pus  in  the 
abdomen,  from  whatever  cause,  demands  incision  of  the  abdominal  wall 
and  free  drainage. 

The  treatment  of  traumatic  peritonitis  will  be  better  understood  when 
the  methods  of  dealing  with  visceral  lesions  have  been  discussed.  Tuber- 
cular peritonitis  and  distention  of  the  abdominal  cavity  with  large  (quan- 
tities of  serous  fluid  have  been  treated  effectually  by  abdominal  section, 
evacuation  of  the  peritoneal  fluid,  and  drainage. 


Tappinr/  the  Abdomen. 

Withdrawing  fluid  from  the  peritoneal  cavity  with  a  trocar  and  cauula 
or  with  an  aspirating  needle  is  called  paracentesis  abdominis. 

An  incision  through  the  abdominal  wall  for  the  purpose  of  exploring 
the  abdominal  contents,  or  to  gain  access  to  the  organs  in  order  to  perform 
operations  upon  them,  is  called  abdominal  section  or  laparotomy. 

Paracentesis  of  the  abdomen  is  seldom  employed  at  the  present  time, 
except  for  the  evacuation  of  serous  fluid  in  the  peritoneal  cavity,  due  to 
cirrhosis  of  the  liver  or  to  disease  of  the  heart  or  kidneys.  Unless  the 
ascitic  fluid  which  distends  the  abdomen  is  known  to  be  due  to  disease  of 
these  organs  it  is  better  for  the  surgeon  to  make  a  small  incision  through 
the  abdominal  wall  and  to  introduce  his  finger.  By  this  means  not  only 
is  the  fluid  which  is  causing  the  distention  evacuated,  but  certain  infor- 
mation as  to  the  cause  of  the  accumulation  of  the  fluid  is  obtained.  One 
or  two  fingers  introduced  through  a  median  incision  an  inch  long,  midway 
between  the  navel  and  the  pubes,  will  be  able  to  explore  the  pelvis  and 
the  abdomen  almost  as  high  as  the  liver.  It  is  readily  seen  that  tumors 
and  other  obscure  conditions  can  be  examined  in  this  way  and  informa- 
tion obtained  which  will  be  a  valuable  guide  to  operative  procedure,  or 
other  methods  of  treatment  to  be  subsequently  adopted. 

The  old  practice  of  tapping  the  abdomen  whenever  it  is  distended  with 
fluid  without  reference  to  the  location  and  cause  of  the  distention  is  now 
looked  upon  with   disfiwor.     Ovarian  cysts  should  not   be  tapped  but 


OPERATING    WITHIN    THE    ABDOMEN    AND    PELVIS.      577 

removed  by  laparotomy.     Many  other  conditions  of  a  similar  character 
which  were  formerly  tapped  are  now  treated  by  radical  means. 

Paracentesis,  therefore,  is  reserved  for  cases  in  which  a  diagnosis  of 
ascites  from  disease  of  the  liver,  kidney,  or  heart  of  a  medical  kind  has 
been  made.  In  obscure  conditions  it  is  proper  to  make  an  exploratory 
incision,  since  tapping  for  the  evacuation  of  the  fluid  gives  no  information 
of  a  definite  kind. 

Before  tapping  the  abdomen  the  bladder  should  be  emptied  and  the 
possibility  of  pregnancy  considered.  The  patient  during  the  operation 
sits  upon  the  edge  of  the  bed,  or  is  propped  up  in  a  semi-recumbent  posi- 
tion by  means  of  pillows.  A  trocar  and  canula,  not  more  than  an  eio-hth 
or  a  quarter  of  an  inch  in  diameter,  is  then  thrust  through  the  belly  wall 
in  the  middle  line  about  two  inches  below  the  umbilicus.  The  forefinger 
of  the  surgeon  should  be  placed  about  an  inch  from  the  point  of  the 
trocar  as  a  guard,  in  order  that  the  instrument  may  not  be  thrust  too  deeply 
into  the  abdomen.  The  instrument  should  be  thrust  through  the  tissues 
with  a  quick  motion  and  with  a  little  rotation,  which  causes  less  pain 
than  a  slow  puncture,  and  insures- the  entrance  of  the  instrument  into  the 
peritoneal  cavity.  The  trocar  and  canula  should,  of  course,  be  aseptic. 
It  is  wise  to  percuss  previously  the  point  at  which  the  perforation  is  to  be 
made,  in  order  to  see  that  no  portion  of  the  bowel  lies  against  the  inner 
surface  of  the  abdominal  wall.  Occasionally  an  adhesion  between  the 
intestine  and  the  parietal  peritoneum  at  this  point  may  have  occurred,  and 
a  resulting  injury  to  the  bowel  from  the  point  of  the  instrument  will 
occur,  unless  by  percussion  giving  a  resonant  note  the  surgeon  suspect 
such  adhesion  and  selects  a  point  dull  on  percussion.  The  possibility  of 
such  an  adhesion  makes  it  wise  to  adopt  a  difierent  point  of  puncture  if 
paracentesis  is  repeated  at  a  subsequent  date  because  of  the  recurrence  of 
the  fluid. 

A  broad,  four-tailed  bandage  placed  around  the  waist  in  such  a  way  as 
to  permit  the  escape  of  the  fluid  from  the  canula  may  be  employed  to 
compress  the  abdomen  as  the  fluid  escapes.  If  the  bandage  should  be 
apphed  before  the  tapping  is  performed  a  hole  may  be  cut  in  it  to  expose 
the  skin  at  the  point  where  the  perforation  is  to  be  made.  The  four  tails 
being  crossed  at  the  back  enables  the  assistant  or  surgeon  to  draw  the  band- 
age more  and  more  tightly  as  the  belly  collapses.  If  the  canula  becomes 
plugged_  by  a  portion  of  omentum  or  lymph  being  washed  into  it,  or  lying 
against  its  end,  an  aseptic  grooved  director  pushed  in  will  cause  the  fluid 
to  flow  anew.  After  the  withdrawal  of  the  canula  the  wound  needs  no 
other  treatment  than  the  application  of  a  piece  of  aseptic  gauze.  If 
oozing  of  serum  continues  from  the  wound  a  suture  may  be  employed; 
this,  however,  is  not  often  required. 

Abdominal  and  Pelvic  Abscesses. 

There  are  many  different  positions  in  the  abdomen  and  pelvis  in  which 
focuses  of  suppuration  may  occur.  Abscess  within  the  layers  of  the  ab- 
dominal wall  is  not  very  unusual.  The  spaces,  or  loculi,  formed  by  cir- 
cumscribed peritonitis  causing  adhesions  between  the  abdomen  and  the 
other  viscera,  or  between  the  viscera  and  belly  wall,  may  contain  pus. 

Difflised  peritonitis  is  not  uncommon.  This  is  not  strictly  an  abscess, 
but  it  is  discussed  at  this  point  because  its  treatment  and  symptoms  are 
those  of  abscess.     It  is  strictly  a  purulent  eff'usion  into  the  peritoneal 


578  DISK  ASKS    OF    THE    ABDOMEN    AND    PELVIS. 

cavity ;  because  an  abscess  is  an  abnormal  cavity  containing  pus,  whereas 
the  peritoneum  is  a  normal  cavity.  Hence  free  pus  in  the  peritoneum  is 
a  juirulent  effusion. 

Abscesses  may  exist  in  the  j)art'nchyn)a  of  one  of  the  solid  viscera, 
such  as  the  liver  and  s])leen.  The  Fallopian  tube  may  become  distended 
Avith  pus  and  orive  rise  to  the  condition  called  pyosalpinx. 

Again,  su])purative  processes  may  occur  behind  the  peritoneum,  in  the 
sj)ace  occupied  by  the  kidneys  and  other  retro-peritoneal  organs.  Abscess 
is  also  po.ssible  between  the  layers  of  the  mesentery ;  while  suppuration 
around  the  vermiform  appendix  and  ca'cum  is  quite  common. 

Parietal  abscess  presents  symptoms  similar  to  abscess  in  other  locations 
and  is  to  be  treated  in  a  similar  manner  by  evacuation  of  the  pus.  It 
derives  its  importance  from  the  fact  that  it,  and  especially  cheesy  or  tuber- 
cular deposits,  or  the  accumulation  of  cheesy  pus  in  this  region,  may  simu- 
late an  abdominal  tumor.  I  recently  ojierated  upon  a  case  in  which  the 
caseous  mass  was  so  hard  and  irregular  in  outline  that  I  was  quite  sure 
that  I  had  a  tumor  within  the  belly  to  deal  with  until  an  incision  revealed 
the  true  character  of  the  condition. 

Localized  supjjurative  peritonitis,  with  the  adherent  viscera,  may  resem- 
ble tumor  within  the  abdomen.  The  proper  treatment  is  laparotomy, 
with  evacuation  of  the  purulent  collection  and  the  insertion  of  drainage- 
tubes.  The  escape  of  pus  into  the  peritoneal  cavity  should  if  po.^sible  be 
prevented  during  the  operation.  Thorough  irrigation  of  the  general  peri- 
toneal cavity  is  demanded  if  any  pus  accidentally  flows  into  it.  Thorough 
drainage  is  essential  in  all  cases  of  visceral  abscesses,  whether  of  liver, 
spleen,  or  ovary.  Abscess  behind  the  peritoneum,  or  within  the  layers 
of  the  mesentery,  should  be  subjected  to  the  same  operative  treatment. 

Pus  in  the  Fallopian  tubes  should  be  treated  by  removal  of  the  tubes 
without  rupture  of  them  during  the  operation,  since  in  this  manner  con- 
tact of  pus  with  the  peritoneal  surfaces  is  obviated.  If  the  tube  becomes 
ruptured  during  its  forcible  separation  from  the  adjacent  structures  to 
which  it  has  liecome  adherent,  the  pelvis  and  abdomen  should  be  well  irri- 
gated and  a  drainage-tube  left  in  the  wound. 

Abscess  of  the  vermiform  appendix  and  ciecum  should  be  treated  in  the 
same  way  as  pelvic  ab-sccss  associated  with  Fallopian  suppuration. 
Removal  of  the  appendix  and  thorough  drainage  of  the  pus  cavity  are 
indicated. 

Diseases  and  Injuries  of  the  Stomach. 

Physical  exploration  of  the  stomach  is  accomplished  by  inspection, 
palpation,  percussion,  and  auscultation  of  the  epigastric  region.  The 
contents  of  the  stomach  removed  by  a  stomach-tube  will,  at  times,  afford 
valuable  information  as  to  the  condition  of  disease.  The  stomach  is 
usually  distended  in  obstruction  of  the  pylorus,  while  depression  of  the 
epigastric  region  occurs  when  the  ingress  of  fo'>d  is  prevented  by  obstruc- 
tion at  the  cardiac  orifice.  The  movements  of  the  stomach  may  be  seen 
at  times  when  it  is  dilated.  Abnormal  growths  may  often  be  seen  and 
felt,  while  these  and  other  conditions  often  give  rise  to  local  pain  or  ten- 
derness on  pressure. 

Tumors  of  the  wall  of  the  stomach  are  examined  with  difficulty,  espe- 
cially if  situated  on  the  left  side  of  the  organ.  There  is  a  tendency  for 
gastric  tumors  to  be  displaced  downward  by  gravitv  ;  hence  thevare  seen 
and  felt  at  a  lower  level  than  would  be  thought  possible  if  this  fact  were 


DISEASES     AND    IXJUEIES    OF    THE    ST0:MACH.  579 

not  remembered.  Percussion  of  the  stomach  gives  a  tympanitic  note. 
This  may,  however,  be  identical  with  the  note  elicited  by  percussion  over 
the  colon.  A  diagnosis  may  at  times  be  made  by  causing  the  patient  to 
drink  a  little  water,  when  the  stomach  loses  its  tympanitic  note,  which, 
however,  the  colon  retains.  The  lower  border  of  the  stomach  is  situated 
about  midway  between  the  sternum  and  the  umbilicus. 

Some  information  of  the  gastric  condition  is  obtainable  by  stethoscopic 
examination,  by  which  various  splashy  and  gurgling  sounds  are  heard 
during  swallowing:  and  dig-estion. 


Foreign  Bodies  in  the  Stomach. 

Coins,  artificial  teeth,  and  other  indigestible  substances  are  liable  to  be 
swallowed  and  become  lodged  in  the  stomach  or  bowels.  It  is  not  wise 
to  give  a  purgative  in  such  cases,  but  it  is  proper  to  delay  the  passage  of 
the  foreign  body  through  the  digestive  tract  by  feeding  the  patient  on  a 
diet  which  is  bulky  and  which  will  surround  the  foreign  body  with  a  mass 
of  fecal  matter.  An  exclusive  diet  of  potatoes  has  been  recommended 
with  this  object  in  view.  If  the  foreign  body  is  too  large  to  pass  with 
safety  through  the  intestine  it  is  necessary  to  remove  it  by  operation,  pro- 
vided there  is  certain  evidence  by  palpation  or  by  the  history  that  the 
foreign  body  is  actually  lodged  in  the  stomach  or  intestines.  Opening 
the  stomach  after  laparotomy  is  called  gastrotomy,  and  is  to  be  distin- 
guished from  gastrostomy,  in  which  a  permanent  orifice  is  made.  These 
operations  will  be  discussed  hereafter.  Opening  the  intestine  is  called 
enterotomy. 

Wounds  of  the  Stomach. 

Rupture  of  the  stomach,  incised  or  gunshot  wounds  of  the  stomach,  and 
perforating  ulcer  of  the  stomach  present  symptoms  similar  to  the  same 
lesions  of  the  intestines,  with  the  addition  of  hsematemesis  or  vomiting 
of  blood.  The  treatment  is  practically  the  same  as  that  for  the  corre- 
sponding lesions  of  the  intestines,  namely :  abdominal  section  with  sutur- 
ing of  the  gastric  wall  (gastrorrhaphy).  Before  such  operations  are  under- 
taken it  is  usually  wise  to  wash  out  the  stomach  with  sterilized  water  by 
means  of  a  stomach-tube.  If  a  portion  of  the  stomach  has  been  injured 
sufiiciently  to  lead  probably  to  local  gangrene,  it  is  often  best  treated  by 
pushing  the  injured  portion  toward  the  interior  of  the  stomach  and 
drawing  the  neighboring  healthy  tissue  over  it  by  sutures.  This  is  done 
in  order  to  prevent  extravasation  of  the  gastric  contents  into  the  peri- 
toneal cavity  when  the  sloughing  occurs.  Lembert's  suture,  which  will 
be  described  under  Intestinal  Wounds,  efiectually  accomplishes  this  object, 
and  is  the  proper  method  of  suturing  to  be  used  in  closing  wounds  or  a 
rupture  of  the  gastric  wall. 

Operations  upon  the  Stomach. 

It  becomes  necessary  to  define  the  various  terms  used  to  describe  opera- 
tions upon  the  stomach. 

Gastrostomy  is  the  formation  of  a  permanent  opening  from  the  exte- 
rior of  the  epigastrium  into  the  stomach,  by.  means  of  which  food  may  be 


580  DISEASES    OF    THE    ABDOMEN    AND    PELVIS. 

introduced.  It  is  performed  in  cases  of  oesophageal  stricture  and  of  malig- 
nant disease  of  the  cardiac  orifice  of  the  stomach. 

Gastrotomy  is  an  inci.<ion  into  the  stomach  ;  and  is  performed  for  the 
removal  of  foreign  bodies,  for  the  purpose  of  dilating  a  strictured  condi- 
tion of  the  pyloric  or  cardiac  orifices,  and  for  the  removal  of  tumor  in- 
volving the  walls  of  the  organ. 

Gastrorrhaphy  is  suturing  of  the  stomach  wall,  and  is  demanded  in 
wounds  or  rupture  of  the  stomach,  and  in  the  treatment  of  perforating 
ulcers  of  the  stomach. 

Pylorectomy  is  a  terra  used  to  exjiress  excision  of  the  pyloric  end  of 
the  stomach  for  malignant  disease,  just  as  gastrectomy  is  applied  to  opera- 
tions for  the  removal  of  any  portion  of  the  stomach. 

Gastroenterostomy  is  the  o])eration  in  which  an  opening  or  fistule  is 
made  between  the  stomach  and  a  neighboring  portion  of  the  intestine.  It 
is  employed  when  the  contents  of  the  stomach  cannot  be  passed  into  the 
duodenum  because  of  the  obstruction  of  the  pyloric  orifice  or  of  the  duo- 
denum. 

Gastrostomy. 

Gastrostomy,  as  is  seen  from  its  derivation,  signifies  a  mouth  in  the 
stomach.  It  is  performed  by  attaching  the  stomach  to  the  anterior  belly 
wall,  and  making  a  permanent  opening  by  which  food  can  be  introduced 
into  the  stomach.  The  operation  is  performed  in  order  to  prolong  life  in 
malignant  diseixse  of  the  oesophagus,  and  to  effect  what  may  practically 
be  a  cure  in  cicatricial  stricture  of  the  oesophagus  due  to  injury.  The 
object  of  the  operation,  of  course,  is  to  prevent  starvation,  which  is  the 
only  cause  of  death  in  cicatricial  stricture.  The  operation  is  somewhat 
more  readily  performed  when  the  stomach  is  distended.  In  cases  of  ob- 
struction in  the  oesophagus  such  as  demand  gastrostomy  the  stomach  is 
apt  to  be  collapsed ;  hence,  if  the  patient  can  swallow  a  few  ounces  of 
water,  it  is,  perhaps,  judicious  to  have  him  do  so  before  the  operation  is 
undertaken.  There  is  not,  however,  sufficient  advantage  gained  to  insist 
upon  repeated  attempts  at  distention  of  the  organ  if  it  gives  the  patient 
annoyance  or  pain. 

The  incision  should  be  made  ])arallel  to  the  costal  border  of  the  lower 
ribs  on  the  left  side,  and  should  be  about  an  inch  from  that  border,  and 
from  an  inch  and  a  half  to  two  inches  long.  The  fistula  which  is  to  be 
made  to  serve  as  an  artificial  mouth  should  be  in  the  angle  between  the 
lower  lobe  of  the  liver  and  the  costal  cartilages,  about  one  inch  from  the 
ribs  and  one  inch  from  the  lower  border  of  the  liver. 

When  the  incision  through  the  abdominal  muscles  has  been  made,  the 
stomach  should  be  carefully  distinguished  from  the  colon,  and  that  part 
of  it  selected  for  the  oi'ifice  which  can  be  attached  readily  and  well  with- 
out making  traction  upon  the  sutures.  It  is  always  wise  to  allow  the 
stomach  to  become  adherent  to  the  belly  wall  before  the  former  is  opened  ; 
hence,  the  gastric  wound  should  not  be  made  until  four  or  five  days  have 
elapsed  after  the  stomach  has  been  sutured  to  the  abdominal  parietes. 
This  precaution  prevents  extravasation  of  the  contents  of  the  stomach 
into  the  peritoneal  cavity,  and  should  be  insisted  upon,  except  in  those 
rare  cases  where  the  condition  of  the  patient  from  starvation  is  so  grave 
that  immediate  opening  of  the  stomach  for  the  introduction  of  food  is 
demanded. 

After  the  abdominal  wound  has  been  made  and  the  stomach  recognized, 


DISEASES    AND    INJURIES    OF    THE    STOMACH. 


581 


two  harelip  pins  should  be  thrust  through  the  integument  and  outer 
tissues  at  the  edges  of  the  wound  and  then  through  the  peritoneal  and 
muscular  coats  of  the  stomach,  so  as  to  fasten  that  organ  against  the  peri- 
toneum covering  the  inner  surface  of  the  abdominal  parietes.  These  pins 
should  be  passed  transversely  to  the  line  of  the  external  abdominal 
wound.  As  a  rule,  these  two  pins  will  be  all  that  is  required  to  hold  the 
stomach  in  contact  with  the  abdominal  surface.  If,  however,  the  condi- 
tion of  the  patient  is  such  that  incision  of  the  stomach  may  be  demanded 
within  a  day  or  two,  a  few  additional  sutures  of  silk  may  be  employed. 
When  immediate  opening  of  the  stomach  is  required,  a  more  complicated 
system  of  suturing  is  necessary,  but,  if  possible,  it  is  wiser  to  allow  four 
or  five  days,  at  least,  to  elapse  before  the  perforation  of  the  stomach  itself, 
since  even  this  short  time  will  permit  a  valuable  degree  of  adhesion  to 
occur  between  the  o-astric  and  abdominal  surfaces. 


When  immediate  operation  upon  the  stomach  is  to  be  done,  the  harelip 
pins  are  not  used.  Two  silver-wire  sutures  are  passed  through  the  perito- 
neal and  muscular  coats  of  the  stomach  by  means  of  a  round-pointed  needle, 
which  is  preferable  for  most  forms  of  abdominal  work  to  the  bayonet- 
pointed  needle.  These  loops  of  silver  wire,  which  are  transverse  to  the 
external  abdominal  wound,  serve  to  draw  up  the  stomach  into  contact 
with  the  inner  margins  of  the  abdominal  incision,  and  to  give  the  sur- 
geon control  of  the  organ.  A  long  silk  suture  is  then  passed  through 
the  two  outer  coats  of  the  stomach  in  the  manner  shown  in  the  diagram, 
so  that  the  ends  of  the  loops  project  upon  the  exterior  of  the  organ. 

By  means  of  a  needle  fixed  in  a  handle,  and  with  a  hook  near  its  point 
instead  of  an  eye,  the  abdominal  wall  is  perforated  opposite  these  loops, 
and  each  loop  by  means  of  the  needle  is  drawn  through  until  it  reaches 
the  exterior  abdomen  a  little  beyond  the  wound.  A  piece  of  rubber  drain- 
age-tube is  carried  around  the  external  opening  of  the  abdomen,  and 
slipped  through  the  loops  made  by  the  silk  sutures.  By  drawing  the  silk 
loops  tightly  down  upon  the  tube  and  tying  the  ends  over  the  tube,  elastic 
pressure  is  made  around  the  whole  circumference  of  the  wound.     Thus 


582  DISEASES    OF    THE    ABDOMEN    AND    PELVIS. 

the  gastric  and  internal  ahdoniinal  surfaces  are  held  closely  in  contact,  so 
that  no  leakaire  from  the  stomach,  which  is  about  to  be  opened,  can  take 
place  into  the  general  peritoneal  cavity. 

The  wire  suture  which  has  been  used  to  draw  up  the  organ  during  these 
manipulations,  can  be  slipped  under  the  tube  and  bent  over  its  upper  surface, 
to  make  the  fixation  more  perfect. 

It  is  to  be  remembered  that  in  passing  the  sutures  through  the  stomach 
wall  the  mucous  coat  is  not  to  be  perforated.  This  is  in  accordance  with 
the  method  of  introducing  sutures  in  operations  on  the  intestines.  If  the 
stomach  is  not  to  be  opened  for  several  days,  ordinary  antiseptic  gauze  is 
placed  over  the  wound  until  the  surgeon  is  ready  to  make  the  ga.stric 
orifice. 

When  the  time  arrives  for  the  performance  of  the  gastric  incision, 
whether  it  is  to  be  done  as  a  part  of  the  original  operation  or  as  a  secondary 
step,  a  very  small  orifice  is  made  through  the  wall  of  the  stomach  by  punc- 
turing it  with  a  knife  or  scissors.  A  rubber  catheter  is  then  slipped  into 
the  interior  of  the  organ.  The  orifice  should  be  very  small,  and  no  food 
should  be  introduced  for  some  time;  then  small  quantities  of  lirjuid  food 
at  a  temperature  of  100°,  given  every  four  hours,  is  proper.  Peptoiiized 
milk,  beef-tea,  and  similar  nourishment  should  be  used.  After  the  first 
few  days,  six  or  eight  ounces  at  a  time  may  be  allowed  to  fiow  slowly  into 
the  stomach. 

The  catheter  is  held  in  place  by  threads  passing  through  it,  or  tied 
around  it  and  fastened  to  the  abdominal  skin  by  adhesive  strips.  Subse- 
quently the  orifice  may  be  enlarged.  After  a  time,  solid  food  may  be 
allowed.  It  may  be  masticated  by  the  patient  before  being  put  into  the 
tube  which  leads  to  the  stomach.  This  method  of  feeding  is  only  adapted 
to  cases  in  which  the  gastric  opening  has  been  dilated  and  increased  after 
the  patient  has  recovered  from  the  original  operation. 

An  absorbent  pad  is  kept  over  the  opening  in  the  intervals  of  feeding. 

Gastrotomy. 

This  word  was  formerly  used  to  denote  what  is  now  more  properly 
called  abdominal  section,  or  laparotomy. 

It  is  used  here  to  signify  incision  into  the  stomach  which  is  subsequently 
to  be  closed,  and  differs,  therefore,  from  gastrostomy,  in  which  the  opening 
made  into  the  stomach  is  permanently  maintained.  Gastrotomy  is  per- 
formed for  the  removal  of  foreign  bodies  that  are  of  such  shape  that  they 
cannot  pass  through  the  intestinal  tract;  for  the  purpose  of  dilating  the 
cardiac  orifices  which  have  become  contracted  by  reason  of  malignant 
growths  or  cicatrices  of  wounds  or  ulcers ;  and  also  for  the  removal  or 
curetting  of  malignant  tumors  involving  the  inner  surface  of  the  stomach. 

The  operation  is,  perhaps,  best  done  after  the  stomach  has  been  washed 
out  with  a  weak  solution  of  bicarbonate  of  sodium  (five  grains  to  the 
ounce),  introduced  through  the  mouth  by  means  of  a  stomach-tube.  If 
this  fluid  escapes  into  the  abdomen  during  the  operation  it  can  readily  be 
sponged  up,  and  is  not  liable  to  irritate  the  peritoneum. 

The  external  incision  should  be  about  two  or  three  inches  long,  and  is 
made  parallel  to  the  costal  cartilages  on  the  left  side,  or  over  the  promi- 
nence made  by  the  foreign  body  in  the  stomach,  if  there  be  any  external 
evidence  of  it.  The  fingers  of  the  surgeon  are  then  carefully  introduced 
into  the  abdomen  to  feel  for  the  stomach.     The  area  of  operation  is  sur- 


DISEASES    AND    INJURIES    OF    THE    STOMACH.  58S 

rounded  with  aseptic  sponges,  and  two  sutures  are  introduced  into  the 
stomach  wall  so  as  to  draw  it  up.  These  sutures  should  be  parallel  to  the 
proposed  gastric  incision,  which,  of  course,  should  be  in  the  same  direction 
as  the  external  wound.  A  round  needle  passed  so  as  not  to  perforate  the 
mucous  coat,  should  be  used  here  as  in  the  operation  for  gastrostomy.  An 
incision  is  then  made  into  the  cavity  of  the  stomach,  subsequently  the 
foreign  body  is  removed  by  the  fingers  or  forceps,  dilatation  of  the  pylorus 
or  of  the  cardiac  orifice  effected,  or  other  operation  contemplated  performed. 
The  gastric  wound  is  then  closed  with  twisted  silk  sutures  after  the  manner 
of  Lembert.  A  sponge  attached  to  a  ligature  should  be  pushed  inside 
the  stomach,  so  as  to  draw  up  the  edges  of  the  gastric  wound.  None  of 
the  sutures  should  be  tied  until  all  have  been  properly  placed,  when  the 
sponge  is  withdrawn  and  the  sutures  tied  securely.  A  second  row  of  sutures 
may  be  placed  between  the  Lembert  sutures.  These  should  be  introduced 
through  the  peritoneum  only,  and  taken  as  ordinary  interrupted  sutures. 

The  patient  must  be  supported  for  three  or  four  days  by  nutrient 
enemas. 

Suturing  gastric  wounds,  whether  accidental  or  operative,  is  called 
gastrorrhaphy. 

Tumors  of  the  Stomach. 

The  tumors  found  involving  the  stomach  walls  are  usually,  though  not 
necessarily,  malignant. 

Malignant  conditions  of  the  stomach  occur  usually  at  the  pyloric  or 
cardiac  orifices,  but  other  portions  of  the  stomach  may  be  the  seat  of 
such  conditions.  The  diagnosis  of  gastric  tumors  belongs  to  medicine 
rather  than  to  surgery. 

The  existence  of  a  tumor  may  be  discovered  by  palpation  of  the  abdo- 
men ;  but  its  relation  to  the  stomach  must  be  determined  by  the  digestive 
and  other  symptoms  accompanying  it. 

Malignant  disease  involving  the  pylorus,  or  diseases  of  a  similar  nature 
occurring  primarily  in  organs  adjacent  to  the  pyloric  portion  of  the 
stomach,  give  rise  in  many  instances  to  stricture  of  the  pylorus.  When 
the  growth  does  not  actually  involve  the  pylorus  it  may  lessen  its  calibre 
by  external  compression.  Non-malignant  stricture  of  this  orifice  may 
also  occur.  It  is  stated  that  there  is  more  anorexia  in  malignant  than  in 
non-malignant  stricture  of  the  pylorus.  Disappearance  of  hydrochloric 
acid  from  the  gastric  juice  is  believed  by  some  writers  to  occur  in  gastric 
carcinoma. 

Excision  of  the  pylorus,  or  pylorectomy,  is  at  times  undertaken  for  the 
removal  of  the  pylorus  for  malignant  disease. 

The  term  partial  gastrectomy  is  employed  to  denote  this,  or,  indeed, 
any  operation  which  removes  a  portion  of  the  stomach. 

Before  excision  of  the  pylorus  is  attempted  the  stomach  should  be 
washed  out  with  a  solution  of  boro-glyceride,  or  with  some  other  non- 
poisonous  antiseptic,  so  that  the  stomach  may  be  empty  as  well  as  aseptic. 
The  incision  should  correspond  with  the  long  axis  of  the  stomach  and 
should  be  about  two  inches  long.  The  pyloric  end  is  then  to  be  separated 
from  the  surrounding  structures  by  means  of  the  finger.  It  is  possible 
that  some  adhesions  may  require  to  be  cut  by  the  scissors,  after  ligatures 
have  been  applied  to  prevent  hemorrhage.  The  diseased  portions  of  the 
stomach  and  of  the  neighboring  duodenum  are  then  removed  with  the 
scissors,  and  the  remaining  portion  of  the  stomach  sutured  to  the  duode- 


584  DISEASES    OF    THE     ABDOMEN    AND    PELVIS. 

nuiu  in  much  the  same  manner  as  is  done  after  excision  or  rasection  of 
the  intestines.  On  account  of  the  stomach  at  the  point  of  excision  having 
greater  calibre  tlian  the  duodenum,  it  becomes  necessary  to  diminish  the 
lumen  of  the  former  in  order  that  it  may  join  the  duodenum  without 
causing  leakage.  This  may  be  done  by  cutting  out  a  V-shaped  portion  of 
the  nmscular  and  peritoneal  coats  of  the  stomach,  which  narrows  its  ori- 
fice. 

In  pyloric  disease  it  will  sometimes  be  better  for  the  surgeon  to  make  a 
permanent  opening  between  the  stomach  above  the  pylorus  and  the  intes- 
tine below  the  duodenum  by  Senn's  method  of  intestinal  anastomosis 
(gastroenterostomy) . 

Stricture  of  Gastric  Orifices. 

A  strictured  condition  of  the  pyloric  or  cardiac  orifices  may  be  due  to 
malignant  disease,  to  cicatricial  contraction  after  ulceration  in  these  re- 
gions, and  perhaps  to  simple  fibrous  hypertrophy,  similar  to  that  causing 
fibrous  stricture  of  the  rectum.  In  these  cases  the  symptoms  may  be  ame- 
liorated or  cured  by  opening  the  stomach,  as  in  ga.strotomy,  and  stretching 
the  contracted  opening  by  means  of  the  fingers  or  some  form  of  dilating 
instrument. 

The  incision  should  be  in  the  median  line  of  the  abdomen.  In  pyloric 
stricture  the  stomach  should  be  opened  about  an  inch  from  the  pylorus 
and  about  midway  between  the  greater  and  lesser  curvatures.  After  one 
finger  has  been  inserted  through  the  contracted  pylorus  a  second  finger 
may  be  introduced  and  sufiicient  stretching  applied  to  bring  the  fingers 
an  inch  and  a  half  to  two  inches  apart.  The  distance,  of  course,  depends 
upon  the  character  of  the  contraction  and  the  peculiarities  of  the  indi- 
vidual case. 

In  operating  upon  a  contracted  cardiac  opening  the  gastric  incision 
should  be  near  the  cardiac  end  of  the  organ.  If  there  is  difiiculty  in 
reaching  the  cardiac  orifice  with  the  fingers,  a  pair  of  dilating  forcej)s, 
similar  to  those  used  for  dilating  the  rectum,  may  be  employed. 

In  malignant  strictures  dilatation  may  add  greatly  to  the  patient's 
comfort  and  is  far  less  dangerous  than  gastrectomy. 


D1SEA.SES  AND  Injuries  of  the  Intestines. 

Foreign  Bodies. 

Foreign  bodies  in  the  intestines  may  require  the  operation  of  enterotomy, 
or  incision  into  the  bowel,  for  their  removal.  The  abdominal  opening 
should  be  made  in  the  median  line,  and  the  bowel  opened  opposite  its 
mesenteric  attachments.  After  the  removal  of  the  foreign  body  the  in- 
testinal wound  is  closed  by  Lembert  sutures. 

Bupttire,  Wounds,  and  Perforating  Ulcers  of  the  Intestines. 

Kupture  of  the  intestines  occurs  from  blows,  and  is  particularly  liable 
to  take  place  when  the  gut  is  greatly  distended  with  gas  at  the  time  of 
injury.  The  symptoms  are  collapse  in  varying  degree,  according  to  the 
extent  of  the  injury,  burning  pain,  feeble  and  irregular  pulse,  and  vomit- 
ing.    After  the  contents  of  the  stomach   have  been  ejected,  blood  and 


DISEASES    AND    INJURIES    OF    THE    INTESTINES.        585 

bile  may  be  vomited.  Tympany  usually  but  not  necessarily  occurs  later, 
after  which  more  marked  symptoms  of  traumatic  peritonitis  supervene, 
and  are  followed  by  death.  If  the  hemorrhage,  extravasation  of  feces, 
or  shock  is  ver}^  great,  death  may  be  immediate. 

Typhoid  fever  ulceration,  giving  rise  to  perforation  of  the  intestine, 
causes  a  similar  set  of  symptoms,  but  these  are  developed,  of  course,  during 
or  after  the  existence  of  typhoid  fever.  In  "walking"  typhoid  fever 
collapse  from  perforation  may  be  the  first  serious  symptom  noticed. 

Rupture,  and  jjerforating  ulcer  of  the  intestines  are  uniformly  fatal. 
There  is  but  one  rational  treatment — immediate  laparotomy  followed  by 
suturing  at  the  point  where  the  solution  of  continuity  has  occurred.  The 
chances  of  saving  life  are  far  greater  in  traumatic  rupture  than  when 
perforation  has  occurred  in  typhoid  fever.  Small  perforations  or  tears 
in  soft  and  almost  gangrenous  gut,  made  during  abdominal  operations, 
may  not  be  amenable  to  suture  because  of  the  friable  condition  of  the 
intestinal  coats.  Here  life  may  at  times  be  saved  by  simply  making  the 
intestinal  tube  straight,  and  preventing  by  mild  laxatives  the  accumula- 
tion of  feces  in  the  diseased  gut.  Thus  strain  is  removed  from  the  region 
of  the  perforation,  and  fecal  extravasation  may  not  occur.  A  drainage- 
tube  should  be  placed  in  the  external  wound.  This  sort  of  surgery  may 
be  safer  than  resection,  which  is  a  prolonged  operation.  It  is  only  admis- 
sible perhaps  in  such  perforations. 

In  all  wounds  of  the  abdominal  wall  which  have  penetrated  into  the 
abdominal  cavity  there  is  danger  of  death  occurring  from  septic  peri- 
tonitis due  to  infection  from  the  insti^ument  at  the  time  of  the  injury,  or 
to  extravasation  of  feces. 

Gunshot  wounds  and  stab  wounds  made  with  a  long  knife  almost  always 
wound  the  hollow  or  solid  viscera.  It  is  probably  best,  therefore, 
always  to  open  the  abdomen  for  the  purpose  of  rendering  aseptic  any 
wound  which  is  not  accompanied  with  visceral  injury,  and  to  repair  the 
damage  to  the  intestines  or  other  organs  in  cases  where  such  dangerous 
traumatisms  have  been  produced. 

Intestinal  wounds  are  dangerous  because  of  the  fecal  extravasation 
which  occurs  always,  unless  the  wound  is  quite  small,  and  because  the 
warmth  of  the  abdominal  cavity  encourages  bleeding  from  injured  ves- 
sels. In  all  cases  of  presumable  intestinal  wound,  abdominal  section 
with  examination  of  the  entire  length  of  the  intestine  is  the  wisest  pro- 
cedure. If  done  in  a  perfectly  aseptic  manner,  according  to  the  princi- 
ples laid  down  in  the  paragraph  on  abdominal  surgery,  it  is  accompanied 
with  no  very  great  risk.  If  no  injury  to  the  viscera  is  found,  the  peri- 
toneal cavity  should  be  simply  washed  out  with  sterilized  water,  or  some 
very  weak  antiseptic  solution,  and  immediately  closed. 

If  from  the  character  of  the  vulnerating  instrument  it  is  probable  that 
septic  infection  has  occurred,  a  corrosive  sublimate  solution  may  be  used, 
but  not  stronger  than  1  to  20,000. 

The  hydrogen  test  of  Senn,  already  described  under  Abdominal  Wounds, 
will  often  give  evidence  that  the  intestine  has  been  perforated  before  the 
belly  wall  is  incised.  Unfortunately,  however,  an  intestinal  wound  may 
exist,  and  the  hydrogen  gas  not  show  it,  because  of  mucous  membrane 
plugging  the  wound  and  preventing  the  escape  of  the  gas. 

After  the  abdomen  has  been  opened  and  intestinal  wounds  found  and 
sutured,  additional  wounds  will  sometimes  be  discovered  with  great  ease 
by  applying  the  hydrogen  test.  Formerly  the  treatment  of  abdominal 
wounds  varied  a  good  deal  with  the  occurrence  or  non-occurrence  of  pro- 


586  DISEASES    OF    THE     ABDOMEN    AND    PELVIS. 

trusiou  of  the  viscera.  At  present  very  little  stress  is  laid  upon  protru- 
sion, since  in  all  cases  the  peritoneal  cavity  must  be  rendered  aseptic  and 
all  complications  treated  on  general  aseptic  principles. 

The  cardinal  rules  are  to  make  the  abdominal  cavity  aseptic,  stop 
hemorrhage,  and  close  the  perforated  intestine  with  sutures.  All  of  these 
procedures  demand  as  a  rule  ininiediate  laparotomy,  which  in  no  instance 
should  be  delayed  beyond  a  very  few  hours.  Promptness  here  is  more 
important  than  in  almost  any  other  Held  of  surgery. 

Enterorrhaphy,  or  suturing  of  the  intestine,  is  the  proper  treatment  for 
wounds,  whether  caused  by  gunshot  or  other  injury.  Lembert's  method 
of  placing  the  sutures  is  uncomplicated  and  most  effective,  and  is  the  one 
now  usually  employed.  The  peritoneal  and  muscular  coats  at  the  two 
sides  of  the  wound  are  punctured  and  drawn  together  by  the  suture,  while 
the  edges  of  the  wound  are  turned  into  the  interior  of  the  intestine.  By 
this  means  rapid  occlusion  of  the  wound  is  obtained  because  the  peritoneal 
surfaces  rapidly  :idhere  by  plastic  e.x;udation.  Hound  needles  are  better 
for  this  purpose  than  bayonet-pointed  needles,  because  there  is  less  bleeding 
from  the  punctures.  The  mucous  membrane  should  not  be  included 
in  the  stitch.  Either  catgut  or  fine  twisted  silk  may  be  used.  All  feces, 
blood,  and  serum  should  be  washed  out  of  the  abdominal  cavity  according 
to  the  rules  adopted  for  abdominal  operations. 

Fig.  369. 


Lembert's  suture.  Lembert's  suture,    a.  serous,  h  muscular,  and 

(AsHHURST.)  c.  mucous  coat.    (Smith.) 

If  the  bowel  is  divided  across  its  calibre  the  ends  must  be  united  by 
circular  suturing,  or  fastened  to  the  belly  wound  so  as  to  form  an  artificial 
anus.  If  the  bowel  or  mesentery  is  so  riddled  with  wounds  as  to  render 
its  preservation  improper,  resection  of  intestine  (enterectomy)  may  be- 
come necessary.  The  cut  ends  may  be  united  by  immediate  circular  suture 
of  the  intestine,  or  if  the  patient's  grave  condition  centra-indicates  this 
long  operation,  the  two  ends  of  the  divided  intestine  may  be  attached  at 
the  point  of  incision,  so  as  to  form  an  artificial  anus.  This  may  be  closed 
some  months  afterward,  when  the  patient  has  recovered  from  the  dangers 
incident  upon  the  original  injury.  Such  a  procedure,  although  not  an 
ideal  operation,  will  often  be  the  means  of  saving  the  patient's  life,  since 
there  is  less  danger  of  fecal  extravasation  occurring  into  the  peritoneal 
cavity,  and  the  patient's  strength  is  not  exhausted  by  the  prolonged 
manipulation  rendered  necessary  by  circular  enterorrhaphy,  which  would 
be  the  case  if  resected  ends  were  at  once  sutured.  Portions  of  the  intes- 
tines which   have  been  subject  to  contusion  or  laceration  occasionally 


DISEASES    AND    INJURIES    OF    THE    INTESTINES.       587 

slough,  and  from  the  perforation  so  produced  extravasation  of  feces 
occurs  secondarily.  Death  may  occur  from  such  pathological  perforation 
after  other  portions  of  the  intestines  which  have  been  subjected  to  sutur- 
ing for  wounds  have  satisfactorily  healed.  Areas  of  gut  which  are  very 
likely  to  slough  had  better,  therefore,  be  turned  into  the  lumen  of  the 
gut  by  Lembert  sutures  passed  beyond  the  slough  margins  in  a  manner 
identical  with  that  which  would  be  necessary  if  the  contained  area  of 
tissue  were  actually  a  perforating  wound. 

Small  orifices  in  the  bowel,  due  to  gangrenous  inflammation,  which  are 
at  times  found  during  abdominal  operations,  do  not  necessarily  cause  fatal 
peritonitis  by  extravasation  of  feces.  If  the  portion  of  gut  so  perforated 
is  placed  in  a  straight  position — that  is,  without  curves — there  will  be 
little  strain  in  the  weakened  wall,  and  often  no  escape  of  feces  will  occur. 
Fecal  extravasation  occurring  in  an  abdomen  which  is  left  opened  so  as 
to  permit  free  drainage  and  washing  is  not  at  all  necessarily  fatal. 

Intestinal  Obstruction. 

Definition. — By  intestinal  obstruction  is  meant  such  a  condition  of 
the  intestinal  calibre  as  prevents  the  passage  of  fecal  matter  through  it. 
The  term  is  not  applied,  however,  when  the  obstruction  is  due  to  strangu- 
lation of  a  hernia,  although  the  conditions  are  practically  the  same. 

Obstruction  of  the  intestine  is  acute  or  chronic,  although  the  acute 
form  may  assume  chronic  characteristics  and  the  chronic  form  may  become 
acute. 

Causes. — The  bowels  may  be  obstructed  by  being  filled  with  gall 
stones,  intestinal  calculi,  or  indigestible  materials  which  have  been  swal- 
lowed ;  by  the  process  of  invagination  or  intussusception,  where  one  portion 
of  the  intestine  is  pushed  into  the  other,  as  the  finger  of  a  glove  may  be 
thrust  backward  into  itself;  by  stricture  of  the  intestinal  coats;  by  adhe- 
sions between  the  intestinal  coils  ;  by  puckering  of  the  mesentery  ;  by  in- 
flammation or  malignant  disease  involving  the  bowel  walls  ;  by  twisting 
and  bending  of  the  intestinal  tube  (volvulus)  ;  by  bands  of  inflammatory 
tissue  strangulating  the  intestine  ;  by  pressure  from  tumors  or  abscesses  ; 
and  by  the  intestines  being  pushed  through  congenital  or  abnormal  holes 
in  the  mesentery  or  omentum,  or  elsewhere,  or  through  orifices  made  by 
inflammatory  deposits. 

Symptoms. — The  symptoms  of  obstruction  vary  as  it  is  acute  or  chronic 
in  character.  In  acute  obstruction  the  pain  is  commonly  marked  and  is 
often  localized  in  a  particular  region  of  the  abdomen,  but  this  locality 
does  not  necessarily  have  to  correspond  with  the  seat  of  the  obstruction. 
Pain  from  strangulation  of  the  intestine  by  a  band  or  other  similar  stric- 
ture is  usually  sudden,  intense,  localized,  and  continuous,  though  it  may 
be  somewhat  relieved  by  external  pressure.  In  stricture  of  the  intestines 
pain  is  said  to  be  more  intermittent  in  character ;  while  in  volvulus  it  is 
more  diflTused  than  localized.  Collapse  and  actual  syncope  is  marked  in 
many  cases  of  intestinal  obstruction,  while  vomiting,  first  of  the  contents 
of  the  stomach  and  subsequently  of  bile,  is  usually  present.  Constipa- 
tion, tenderness,  swelling,  and  distention  of  the  abdomen  are  marked 
symptoms.  The  rolling  of  the  distended  intestines  over  each  other  from 
interference  with  normal  peristaltic  action  causes  at  times  marked  gur- 
gling. If  the  abdomen  is  thin  the  hands  placed  upon  its  surface  may  feel 
the  motion  of  the  intestines,  and  at  times  even  locate  the  seat  of  the  ob- 


588 


DISEASES    OF    THE    ABDOMEN    AND    PELVIS. 


striiction.  Exhaustion,  peritonitis,  and  gangrene  are  the  usual  causes  of 
death.  In  acute  intestinal  obstruction  death  occurs  in  from  one  to  seven 
days. 

In  intussusception  the  portion  of  the  gut  which  is  pushed  into  the 
adjoining  i)art  of  the  intestine  may  slough  oH"  because  of  the  constriction 
made  upon  it  by  the  sheath  which  grasps  it,  and  be  discharged  from  the 
anus.  The  continuity  of  the  calibre  of  the  intestine  may  be  reestablished 
iu  this  way,  because  during  the  stage  jirecediug  sloughing  the  walls  while 
in  contact  have  become  united  by  inflammatory  adhesions. 

In  chronic  obstruction  of  the'  bowels  pain  and  vomiting  are  often  not 
very  marked,  but  obstinate  constipation  is  a  prominent  sign.  Tympan- 
ites does  not  occur  early  in  such  cases,  but  when  it  occurs  it  is  marked. 
S])ontaneous  recovery  sometimes  takes  place,  while  death,  which  is  a 
common  result,  does  not  occur  until  after  six  or  eight  weeks. 

Diagnosis. — In  making  a  diagnosis  of  intestinal  obstruction  the  possi- 
bility of  impaction  of  feces  in  the  rectum,  and  of  strangulated  hernia 
must  be  excluded.  The  surgeon  should  remember  also  that  constipation 
of  an  obstinate  kind  may  occur  in  enteritis  and  peritonitis,  and  also  in 
inflammation  of  an  undescended  testicle. 

It  is  important  to  determine  the  cause  of  the  obstruction  and  to  learn 
whether  the  case  is  of  an  acute  or  chronic  character.  Lead  colic  may 
mislead  the  careless  examiner. 

A  short  consideration  of  the  special  symptoms  of  the  various  forms  of 
intestinal  obstruction  will  here  be  proper. 

Intussusception,  or  prolapse  of  one  portion  of  the  bowel  into  the  lumen 
of  an  adjoining  portion,  occurs  most  commonly  in  children,  and  is  the 
most  frequent  form  of  intestinal  obstruction.  The  invaginated  portion, 
or  intusussceptum,  usually  is  above  the  portion  into  which  it  passes,  which 
is  called  the  intussuscipiens,  or  sheath.  Occasionally,  however,  invagina- 
tion takes  place  upward. 

Fig.  :!71. 

Kiinntrcl    flcimv ^ 


TCturntni)  _ 


Intussusception,:  with  a  diagram  showing  the  entering,  returning,  and  receiving 
layers  of  ileum  into  colon.     (Bryant.) 

Polypus  of  the  intestine,  worms,  or  undigested  food  may  be  a  cause  of 
intussusception.  It  is  believed  by  some  writers  that  many  cases  of  colic 
in  children  are  instances  of  intussusception,  which  have  corrected  them- 
selves before  inflammatory  adhesion  of  the  invaginated  coats  has  taken 
place. 

The  sheath,  or  intussuscipiens,  having  grasped  the  invaginated  portion, 
forces  it  along  by  peristaltic  action,  gradually  "  sucking  in  "  or  "  swallow- 
ing "  more  of  the  intestine,  just  as  a  mass  of  feces  is  pushed  along  the 
intestinal  canal.     Epithelioma  is  at  times  found  involving  the  invaginated 


DISEASES    AND    INJURIES    OF    THE    INTESTINES.      589 

gut.  It  is  a  question  in  these  cases  whether  the  disease  has  occurred 
after  the  process  of  invagination,  or  whether  the  malignant  mass  was  the 
origin  of  the  process  of  invagination. 

The  most  prominent  symptom  of  intussusception  is  a  constant  desire  to 
go  to  stool.  With  this  is  associated  a  discharge  of  mucus  and  blood  from 
the  rectum.  Fecal  vomiting  is  not  so  often  present  as  in  some  other  forms 
of  obstruction.  A  sausage-shaped  mass  may  at  times  be  felt  or  seen 
through  the  abdominal  wall.  This  is  more  frequently  found  on  the  left 
side  of  the  belly.  In  children  it  is  not  uncommon  to  feel  the  invaginated 
portion  by  the  finger  introduced  into  the  rectum.  The  accumulation  of 
feces,  which  takes  place  above  the  seat  of  obstruction,  is  occasionally 
perceived  by  palpation.  It  is  apt  to  be  upon  the  right  side  of  the  abdo- 
men, and  can  be  indented  or  pitted  by  the  fingers  pressed  upon  the  exterior. 
This  symptom  is  almost  pathognomonic.  Invagination  may  occur  without 
obstruction  to  the  passage  of  the  feces,  unless  swelling  of  the  mucous  and 
other  coats  causes  obliteration  of  the  lumen.  Otherwise  obstinate  consti- 
pation supervenes.  When  these  symptoms  do  not  occur,  a  certain  amount 
of  patency  to  the  canal  is  retained. 

Internal  strangulation  by  inflammatory  bands,  or  by  orifices  in  the  mes- 
entery, or  omentum,  or  by  rings  caused  by  foetal  structures  which  have 
remained  within  the  abdomen,  is  often  called  internal  hernia.  Its  most 
marked  symptom  is  intense  prostration  or  syncope.  It  does  not  often 
occur  in  infants  or  in  the  aged.  It  presents,  of  course,  the  symptoms 
which  have  been  described  as  indicative  of  obstruction. 

Twist  of  the  bowel  (volvulus),  occurs  particularly  in  old  people,  and 
usually  at  the  sigmoid  or  ileo-csecal  region.  Actual  knotting  of  the  bowel 
has  been  discovered.  The  prostration,  however,  is  not  so  extreme  as  in 
internal  strangulation.  The  abdomen  is  often  unevenly  distended,  one  side 
being  rather  flattened,  while  the  other  is  remarkably  tympanitic.  It  is  the 
right  side  which  most  frequently  shows  flattening,  because  the  sigmoid 
portion  of  the  colon  is  the  most  frequent  seat  of  trouble.  The  accumula- 
tion of  gas  in  the  intestines  is  rapid  and  great. 

Obstruction  from  stricture  or  tumor  is  usually  chronic,  and  affects  the 
lower  bowel  more  frequently  than  the  upper.  A  history  of  gradual  con- 
stipation can  at  times  be  obtained,  and  thus  aid  in  the  differential  diag- 
nosis. Acute  symptoms,  however,  may  suddenly  become  engrafted  upon 
such  a  condition  of  chronic  obstruction,  and  thus  add  to  the  difficulty  of 
accurate  diagnosis. 

Diagnosis. — Obstruction  in  the  smaH  intestine  is  more  apt  to  be  rapid 
in  course,  and  accompanied  with  greater  pain,  than  is  the  same  condition 
in  the  large  intestine.  Early  vomiting  is  more  conspicuous  in  obstruction 
of  the  small  than  of  the  large  intestine.  In  other  words,  acute  symptoms, 
except  in  the  case  of  volvulus,  are  apt  to  be  associated  with  obstruction  of 
the  small  intestine,  while  chronic  symptoms  are  usually  due  to  obstruction 
of  the  colon.  Less  urine  is  secreted,  it  is  said,  as  the  stricture  is  tighter. 
Some  writers,  however,  believe  that  the  diminution  of  urine  is  connected 
with  the  position  in  the  intestinal  tube  at  which  the  obstruction  occurs. 
The  nearer  the  stomach  the  obstruction  takes  place,  the  less,  it  is  stated, 
is  the  secretion  of  urine. 

Treatment. — The  treatment  of  obstruction  should  be  prompt,  but 
should  never  consist  in  the  administration  of  purgatives.  If  the  diagnosis 
has  been  made  before  inflammation  of  the  peritoneum  and  distention  of 
the  abdomen  have  taken  place,  and  before  the  patient  has  been  exhausted 
by  the  disease,  or  his  condition  made  more  hazardous  by  the  administration 


590  DISEASES    OF    THE    ABDOMEN    AND    PELVIS. 

of  purgatives,  the  possibility  of  relief  is  much  increased.  All  cases  are 
exceedingly  dangerous,  but  the  danger  is  often  increased  by  injudicious 
attempts  at  purgation.  The  existence  of  hernia  at  any  of  the  usual  situa- 
tions, or  the  presence  of  impacted  feces  in  the  rectum,  must  first  of  all  be 
excluded.  When  this  has  been  done,  and  enteritis  and  peritonitis  as  a 
cause  of  the  symj)tom  can  be  set  aside,  abdominal  section  should  be  per- 
formed as  an  exploratory  measure  within  a  few  hours  after  the  occur- 
rence of  obstruction  ;  provided  that  attempts  to  relieve  the  obstruction  by 
large  enemas  have  failed. 

Enemas  of  warm  water  or  oil  should  be  given  by  means  of  a  long  tube, 
introduced  preferably  when  the  patient  is  in  the  knee-elbow  position.  This 
position  will  allow  gravity  to  act,  and  will  aid  in  the  introduction  of  very 
large  quantities  of  liquid  into  the  bowel.  The  hydrostatic  pressure  may 
be  increased  by  raising  the  fountain  syringe,  or  other  reservoir,  several  feet 
above  the  patient.  This  can  be  done  by  the  surgeon  mounting  a  chair  or 
step-ladder.  Such  large  enemas  are  of  value  in  softening  fecal  accumula- 
tion, and  are  capable  of  altering  the  abnormal  positions  or  twists  in  the 
bowel  which  are  causing  the  symptoms.  Inflation  of  the  intestine  with  air 
forced  in  by  means  of  a  long  tube,  connected  with  a  stomach-pump  and 
introduced  into  the  rectum,  has  its  advantages. 

If  these  means  fail,  a  median  incision  into  the  abdominal  cavity  should 
be  made,  and  two  fingers  introduced  to  explore  the  peritoneal  cavity  and 
determine  the  cause  of  the  obstruction.  A  short  distance  below  the 
umbilicus  is  usually  the  most  advantageous  point  for  the  section,  unless 
palpation  gives  evidence  of  a  higher  point  in  the  median  line  being  prefer- 
able. Usually  the  distended  intestine  will  l)e  discovered  forcing  its  way 
through  the  incision.  The  most  dilated  portion  should  be  seized  and  the 
bowel  followed  along  in  the  direction  of  the  greatest  distention  and  the 
greatest  congestion.  This  will  usually  lead  to  the  point  of  obstruction. 
Greig  Smith  states  that  this  method  is  more  satisfactoiy  and  more  practi- 
cable than  attempts  to  find  the  most  constricted  portion,  and  to  follow  it 
to  the  seat  of  obstruction. 

If  a  foreign  body  is  found,  the  gut  should  be  opened  and  the  body  re- 
moved. If  it  is  a  gall-stone  it  will,  perhaps,  be  possible  to  split  it  up  into 
fragments  by  introducing  a  needle  through  the  intestinal  wall.  A  volvulus 
or  internal  strangulation  mavbe  relieved  by  untwisting  the  coils  of  gut  or 
cutting  through  the  constricting  bands.  A  stricture  of  the  gut  may  be 
treated  by  opening  the  intestine  and  dilating  the  stricture  by  means  of  the 
fingers,  as  has  been  described  in  the  treatment  of  strictures  of  the  gastric 
orifices.  If  it  is  impossible  to  deal  with  the  stricture  in  this  way,  the  dis- 
eased portion  may  be  excised,  or  the  intestine  may  be  opened  above  the 
obstruction  and  stitched  to  the  external  abdominal  wound  so  as  to  form 
an  artificial  anus.  It  may  be  preferable  in  some  cases  to  form  a  commu- 
nication between  the  intestine  above  the  seat  of  the  disease  and  that  below 
it,  by  means  of  intestinal  anastomosis. 

In  intussusception  the  invaginated  portion  may  perhaps  be  withdrawn 
from  the  sheath  or  intussuscipiens.  If  this  is  impossible,  the  establish- 
ment of  an  artificial  anus,  the  performance  of  lateral  anastomosis,  or 
resection  of  the  bowel  will  be  proper. 

This  line  of  treatment  is  that  which  should  be  adopted  in  cases  of  acute 
intestinal  obstruction. 

In  chronic  cases  the  adoption  of  operative  measures  is  not  so  vigorously 
demanded,  but  the  case  should  be  watched.  No  purgatives  should  be 
given  and  large  enemas  should  be  used.     The  patient  should  be  kept 


DISEASES    AND    INJURIES    OF    THE    INTESTINES.      591 

upon  concentrated  food  given  in  small  quantities.  In  this  manner  the 
strength  is  retained  without  the  formation  of  large  quantities  of  fecal 
matter.  x\fter  this  treatment  has  been  carried  on  unsuccessfully  for  about 
a  week,  abdominal  section,  with  the  performance  of  such  intra  abdominal 
operations  as  may  be  suitable  for  the  condition  discovered,  is  proper. 

In  patients  that  have  been  allowed  to  suffer  until  their  strength  is  ex- 
hausted and  their  general  condition  exceedingly  bad,  the  administration 
of  general  ansesthesia  may  be  ill-advised.  Greig  Smith  wisely  suggests 
in  such  cases  that  an  abdominal  incision  should  be  made  under  local 
anaesthesia  by  means  of  cocaine.  A  quick  exploration  of  the  abdomen 
should  then  be  made  and  the  bowel  opened  at  any  convenient  point  and 
stitched  to  the  abdominal  wound  in  order  to  establish  an  artificial  anus. 
This  rapid  operation  will  cause  but  little  shock,  and  will  relieve  the  im- 
mediate symptoms.  Several  weeks  after,  when  the  patient  has  attained  a 
better  general  condition,  the  artificial  anus  should  be  dealt  with  and  more 
radical  measures  adopted. 

In  all  cases  of  intestinal  obstruction  it  is  important  that  the  great  dis- 
tention of  the  intestines  which  exists  should  be  relieved  at  the  time  of 
the  operation  for  the  treatment  of  the  obstruction.  This  is  best  done  by 
drawing  out  of  the  abdomen  a  coil  of  the  distended  gut,  receiving  it  upon 
a  warm  antiseptic  towel  and  making  an  incision  into  it  through  which  the 
gas  and  fecal  matter  may  be  forced  out  by  manipulation  of  the  adjoining 
coils.  The  incision,  which  should  not  be  more  than  three-fourths  of  an 
inch  in  length,  should  be  transverse  to  the  axis  of  the  bowel  and  upon 
the  side  opposite  to  the  mesentery.  After  the  large  quantities  of  gas  and 
all  fecal  matter  in  the  vicinity  have  escaped  the  intestinal  wound  is  closed 
by  Lembert  sutures  and  the  intestine  replaced. 

Tumors  of  the  Intestines  and  Omentum. 

Tumors  of  various  kinds  occur  in  the  intestinal  walls.  Malignant 
growths  are  more  frequent  than  other  solid  tumors  in  this  site,  and  are 
more  common  in  the  large  than  in  the  small  bowel.  The  omentum  may 
also  be  the  seat  of  solid  growths,  as,  indeed,  may  be  the  mesentery.  Hy- 
datid tumors  are  not  very  infrequent  in  the  abdominal  organs  in  certain 
portions  of  the  world. 

The  symptoms  of  tumor  connected  with  the  bowel  or  the  adjacent  tis- 
sues are  pain,  ascites,  intestinal  obstruction,  and  subacute  peritonitis. 
The  symptoms,  however,  vary  with  the  character  of  tumor  and  its  loca- 
tion. The  abnormal  mass  is  often  detectable  by  palpation  of  the  abdomen, 
especially  if  the  examination  is  made  previous  to  the  occurrence  of  ab- 
dominal dropsy  due  to  obstruction  of  the  venous  current  occasioned  by 
pressure  on  the  portal  vein  and  its  branches. 

The  treatment  of  such  growths  consists  in  laparotomy,  followed  by 
drainage  or  excision  in  the  case  of  cystic  tumors,  and  by  such  operations 
as  will  effect  the  radical  removal  of  solid  tumors  or  overcome  the  condi- 
tions induced  by  them.  Resection  of  the  intestine  or  the  establishment  of 
a  new  route  for  the  intestinal  contents  by  means  of  intestinal  anastomosis 
or  the  creation  of  an  artificial  anus,  will  be  the  proper  procedure  in 
selected  cases. 

Operations  on  the  Intestines. 

Opening  the  small  intestine  for  the  removal  of  a  foreign  body,  or  for 
any  other  cause,  is  called  enterotomy.     Resection  of  the  small  intestine  is 


592  DISEASES    OF    THE    ABDOMEN    AND    PELVIS. 

enterectomy  ;  while  suturing  of  a  wound  of  the  small  intestine  is  enteror- 
rhaphy. 

Colotomy  should,  in  the  strict  sense  of  the  term,  mean  opening  the 
colon,  but  it  is  frequently  employed  to  designate  the  formation  of  a  per- 
manent opening  between  this  intestine  and  the  external  air.  This  should 
really  be  called  colostomy.  Colectomy  is  the  excision  or  resection  of  a 
portion  of  the  colon. 

Enterotomy,  enterectomy,  and  enterorrhaphy  are  often  used  to  designate 
operations  on  either  the  large  or  small  intestine. 

Artificial  Anus. 

An  artificial  anus  is  a  permanent  opening  between  the  intestinal  canal 
and  the  air,  through  the  abdominal  wall,  by  means  of  which  the  feces  are 
extruded.  The  opening  may  lead  into  either  the  small  or  the  large  intes- 
tine. When  only  a  small  portion  of  the  feces  escapes  through  such  an 
orifice,  and  the  remainder  is  evacuated  at  the  normal  anus,  the  communi- 
cation between  the  external  air  and  the  intestinal  canal  is  more  accurately 
called  a  fecal  fistule.  Such  openings  are  made  intentionally,  in  order  to 
save  life  during  the  performance  of  some  abdominal  operation ;  or  they 
are  the  result  of  sloughing  of  the  intestine  after  it  has  become  adherent 
by  indammation  to  the  parietes  of  the  abdomen.  Sloughing  of  the  knuckle 
of  the  gut  in  strangulated  hernia  is  quite  frequently  the  cause  of  artificial 
anus. 

The  bowel  around  the  seat  of  the  opening  is  adherent  to  the  parietal 
peritoneum  at  the  margin  of  the  opening.  In  accidental  cases  the  orifice 
or  fistule  is  usually  distorted  and  depressed,  while  the  surrounding  skin 
is  the  seat  of  eczematous  inflammation.  There  may  be  two  parallel 
intestinal  tubes  with  their  adjoining  walls  adherent  at  the  seat  of  the 
artificial  anus,  or  there  may  be  but  a  small  opening  in  the  bowel  which 
is  attached  to  the  belly  wall  without  any  bending  of  the  intestine.  In 
the  former  case  the  artificial  anus  is  due  to  the  sloughing  away  of  the  bent 
portion  or  knuckle  of  intestine  which  formerly  connected  the  two  tubes, 
now  lying  parallel  to  each  other.  The  upper  portion  of  the  gut,  that  is 
the  portion  nearest  the  stomach,  is  usually  dilated,  and  from  it  the  feces 
escape  ;  while  the  lower  portion  of  the  gut  is  collapsed.  This  lower  por- 
titm  of  the  gut  may,  rarely,  be  situated  at  the  up[)er  portion  of  the  ab- 
dominal opening.  By  rotation  it  has  become  uppermost,  and  then  adhered 
to  the  upper  part  of  the  belly  wall  befoi-e  the  sloughing  occurred.  We 
employ  the  term  upper  in  a  technical  sense  to  mean  the  portion  of  the 
intestine  which  is  furthest  from  the  rectum. 

Usually,  there  is  a  spur  or  partition  between  the  two  tubes,  which  is  the 
remains  of  the  adjoining  walls  of  the  normal  intestine  at  the  point  of 
Hexion.  It  is  this  spur  which  tends  to  cause  extrusion  of  the  entire  fecal 
contents  through  the  abnormal  anus.  If  this  is  absent  the  contents  of  the 
bowel  may  continue  down  the  tube  and  escape  in  the  normal  manner, 
with  very  little  escape  occurring  through  the  abdominal  orifice ;  which  is 
then  a  fecal  fistule  rather  than  an  artificial  anus. 

Operation  may  be  demanded  to  repair  such  an  artificial  anus  or  fecal 
fistule.  It  is  important  that  it  be  undertaken  before  the  lower  portion  of 
the  gut  has  become  so  shrivelled  or  atrophied  as  to  be  quite  different  in 
calibre  from  the  upper  tube.  If  the  artificial  anus  has  occurred  high  up 
in  the  ileum  or  jejunum,  the  chyle  escapes  from  the  intestinal  tract  and 


DISEASES    AXD    IXJUEIES    OF    THE    INTESTINES.        593 


causes  the  patient  to  suffer  from  partial  or  complete  starvation.  The  con- 
dition then  demands  operative  interference  because  of  the  difficulty  in 
nourishing  the  patient,  as  well  as  on  account  of  the  disagreeable  nature  of 
the  disease. 


Fig.  372. 


Diagram  showing  various  relations  of  upper  (U)  and  lower  (L)  portions  of 
intestine  with  spur.     (Greig  Smith.) 


The  introduction  of  hydrogen  gas  through  the  rectum,  already  described 
under  Wounds  of  the  Abdomen,  is  a  means  of  proving  the  relative  locality 
of  the  opening.  If  the  artificial  anus  is  in  the  large  intestine,  the  gas  will 
escape  from  the  abnormal  orifice  very  soon  after  being  introduced  into  the 
rectum,  and  there  will  be  no  gurgling  heard,  such  as  is  produced  when  the 
gas  passes  the  ileo-ceecal  valve.  The  time  elapsing  before  the  gas  escapes 
from  the  abnormal  opening,  if  it  be  in  the  small  intestine,  will  indicate 
the  relative  situation  of  the  opening  in  the  small  gut. 

Simple  means  of  closing  an  artificial  opening  should  be  adopted  before 
the  more  complicated  and  dangerous  procedures  are  undertaken.  When 
there  is  no  spur,  or  when  only  a  very  small  orifice  exists,  it  is  possible  to 
cure  the  condition  by  the  application  of  the  cautery ;  by  paring  the  edges 
of  the  fistule  and  suturing  them  together  ;  or  by  covering  the  opening  by 
a  flap  of  skin  dissected  from  the  surrounding  surface  after  the  edges  of 
the  opening  have  been  freshened  and  stitched  together. 

When  a  spur  directing  the  fecal  matter  through  the  openmg  exists,  it 
is  necessary  to  remove  this  partition  by  pushing  it  downward,  or  dividing 
it,  so  as  to  restore  the  continuity  of  the  intestinal  calibre.  Mere  removal 
of  this  obstruction  may  cause  spontaneous  closure  of  the  artificial  anus. 
A  simple  method  of  depressing  the  spur  is  to  push  into  the  opening  a  piece 
of  stiff  rubber  tubing,  which  is  bent  into  a  sort  of  horseshoe.     The  two 

38 


594 


DISEASES    OF    THE    ABDOMEN'     AND    I'ELVIS. 


ends  are  thrust  into  the  opening  of  the  tube,  and  by  their  tendency  to 
separate  the  spur  is  pressed  downward.  The  bent  tube  can  be  removed  at 
any  time  by  means  of  a  string  which  has  been  attached  to  it.  When  the 
spur  is  hirge  and  thickened  it  becomes  necessary  to  divide  it.  This  is  best 
done  by  an  enterotome,  which,  in  brief,  is  a  long,  two-bhided  clamp,  by 
which  the  spur  is  grasped  and  held  for  several  days,  until  the  pressure 
causes  sloughing  of  the  portion  of  the  spur  l)etween  the  jaws.  If  the  claraj) 
cuts  too  rapidly,  there  is  possibility  of  a  perforation  extending  into  the 
general  peritoneal  cavity,  particularly  if  the  blades  grasp  a  portion  of  the 
intestinal  walls  at  the  base  of  the  spur  which  have  not  previously  been 
adherent  to  each  other. 

The  best  form  of  enterotome  is  that  in  which  the  blades  have  ring-like 
e.Ktremities.  This  instrument  causes  sloughing  in  a  circle  and,  therefore, 
removes  a  disk  of  the  spur,  instead  of  making  a  simple  incision  through  it. 

Fig.  :57;i. 


a,  Eaterotome  :  6,  enterotome  ai>plied.    (Ashhurst.) 

The  opening  upon  the  surface  of  the  abdominal  wall  is  to  be  closed  by 
a  suitable  plastic  operation,  unless  spontaneous  closure  occurs  soon  after 
restoration  of  the  line  of  the  bowel  by  the  removal  of  the  obstructive 
spur. 

Resection  of  the  intestine  on  both  sides  of  the  artificial  anus,  and  imme- 
diate suturing  of  the  two  ends  of  the  gut  thus  obtained,  is  a  method  of 
treating  artificial  anus  seldom  adopted,  because  of  its  greater  danger  than 
the  method  just  described.  It  is  justifiable,  however,  in  certain  cases 
■when  milder  measures  fail. 


Appendicitis  and  Typhlitis. 

Pathology. — Inflammation  of  the  ciecura  is  called  typhlitis ;  inflam- 
mation in  and  around  the  caecum  perityphlitis,  and  inflammation  of  the 
vermiform  appendix  appendicitis. 

Tiie  terms  typhlitis  and  perityphlitis  formerly  included  all  inflamma- 
tions in  this  region,  but  it  is  now  believed  that  the  majority  of  cases  are 
instances  of  appendicitis. 

Foreign  bodies,  which  may  have  been  swallowed,  may  become  impacted 
in  the  vermiform  appendix.    Small  masses  of  hardened  feces,  grape  seeds. 


DISEASES    AND    INJURIES    OF    THE    INTESTINES.        595 

and  small  bones  are  quite  often  the  cause  of  inflammation  of  the  appendix 
and  the  structures  in  the  iliac  fossa.  It  is  not  unusual  for  perforation  of 
the  appendix  to  occur  subsequently  to  such  impaction  and  irritation,  or, 
perhaps,  from  simple  ulceration  of  its  coats.  Such  perforative  appen- 
dicitis is  acute  and  gives  rise  to  violent  general  peritonitis.  If  the  con- 
dition, however,  is  a  chronic  one,  adhesions  occur  about  the  appendix  and 
shut  off  the  suppurative  focus  from  the  general  peritoneal  cavity.  The 
symptoms  thus  caused  are  less  rapid,  though  often  fatal. 

Repeated  attacks  of  sub-acute  inflammation  in  this  region  are  seen  in 
not  a  few  patients.  It  is  probable  that  the  recurrence  is  due  to  patho- 
logical changes  associated  with  appendix  disease.  It  is  now  believed  that 
such  disease  of  the  appendix  is  a  source  of  risk  to  the  patient,  and  opera- 
tions are  done  to  remove  this  worm-like  organ  during  the  stage  of  quiet 
after  a  second  or  third  attack  of  inflammation. 

Symptoms. — The  differential  diagnosis  between  typhlitis,  perityphlitis, 
and  inflammation  of  the  colon  above  the  csecum  is  not  very  easy  to  make, 
except  in  the  typical  cases  where  the  localization  of  symptoms  and  their 
acuteness  indicate  the  portion  of  intestine  involved. 

Sudden  perforation  of  the  intestine  gives  rise  to  pain  and  profound  col- 
lapse, vomiting,  tympany,  suppurative  peritonitis,  and  death.  This  may 
occur  to  a  patient,  to  all  appearances,  previously  in  perfect  health.  Ordi- 
narily, however,  perforation  does  not  occur  except  after  previous  inflam- 
matory symptoms. 

In  chronic  cases  there  is  pain,  more  or  less  severe  in  character,  in  the 
iliac  region,  with  reflected  pain  in  the  groin,  hip  and  front  of  the  thigh. 
Great  tenderness  upon  pressure  in  the  csecal  region  is  apt  to  be  present, 
and,  from  spasm  of  the  psoas  muscle  in  the  effort  to  avoid  pain,  the  thigh 
is  usually  flexed  on  the  pelvis.  The  bowels  may  be  bound,  but  some- 
times they  are  actually  loose,  so  that  a  condition  of  diarrhoea  is  present. 
At  other  times  impaction  of  the  feces  occurs,  causing  a  hard  mass  to  be 
felt  in  the  csecal  region. 

The  symptoms  are  those,  therefore,  of  localized  peritonitis,  with  corre- 
sponding constitutional  phenomena.  A  hard,  doughy  mass,  the  size  of  a 
fist,  may  be  found  on  palpation  of  the  abdominal  surface.  This  indura- 
tion may  also  be  discovered  by  rectal  exploration  wdth  the  finger  or  the 
inserted  hand.  Resolution  may  take  place  after  two  or  three  weeks' 
illness,  or  evidences  of  suppuration  may  supervene.  Rigors,  high  tem- 
perature, especially  at  night,  and  other  hectic  symptoms  are  not  unusual. 
If  the  pus  burrows  under  the  peritoneum  covering  the  lateral  and  pos- 
terior wall  of  the  abdomen,  the  symptoms  are  not  so  startling  as  when 
pus  eflfects  an  entrance  into  the  general  peritoneal  cavity.  Even  in 
appendicitis  the  pus  may  be  walled  in  and  prevented  from  entering  the 
peritoneal  cavity  by  a  chronic  adhesive  inflammation  which  has  been 
produced  about  the  seat  of  perforation. 

Treatment. — In  chronic  cases  of  such  inflammation  the  patient  should 
be  put  to  bed  and  given  saline  laxatives,  but  not  active  purgatives.  Mor- 
phia and  atropia  combined,  and  in  moderate  doses,  may  be  given  to 
relieve  pain,  though  the  use  of  these  remedies  is  to  be  deprecated,  as  their 
tendency  is  to  mask  symptoms  and  thus  to  prevent  early  operation  in 
appropriate  cases.  Leeches  may  be  applied  locally,  or  a  blister  used  for 
counter-irritation.  Abundant  enemas  of  warm  water,  inti'oduced  by 
means  of  a  long  rectal  tube,  are  very  valuable.  Too  great  pressure,  how- 
ever, should  not  be  employed  lest  the  inflamed  and  softened  intestine  be 


596  DISEASES    OF    THE    ABDOMEN    AND    PELVIS. 

ruj)tured.  Perforation  due  to  repeated  or  over-zealous  examination  of 
the  iliac  fos;:a  with  the  fingers  has  occurred. 

In  sub-acute  ciises  the  line  of  treatment  just  mentioned  should  be  insti- 
tuted, but  preparations  for  laparotomy  should  be  made  so  that  no  delay 
need  occur  after  the  advent  of  acute  symptoms  indicating  perforation. 

In  acute  perforaticm  immediate  lajiarotomy  should  be  done  without 
waiting  for  the  development  of  fatal  peritonitis. 

In  chronic  cases  delay  of  operation  is  wise,  but  if  local  oedema,  rise  in 
temperature,  and  fluctuation  give  evidence  of  the  existence  of  pus,  an 
exploratory  operation  should  be  performed. 

It  often  happens  that  a  patient  will  have  inflammation  of  the  iliac 
fossa,  which  never  again  is  repeated,  but  in  other  instances  inflammatory 
svmptoms  supervene  at  irregular  intervals  without  apparent  cause,  or  sub- 
sequently to  violent  exerticm,  or  to  indiscretion  in  diet.  As  such  repeated 
attacks  cause  a  condition  of  chronic  ill  health,  it  is  proper  during  one  of 
the  periods  of  quiet  to  open  the  abdomen  and  remove  the  appendix,  if  it 
is  found  to  be  diseased,  as  will  nearly  always  be  the  case. 

Chronic  pain  in  this  region  has  been  relieved,  it  is  stated,  by  removing 
an  api)arently  healthy  appendix,  which,  however,  on  being  opened  revealed 
the  existence  of  ulceration  of  its  raucous  surface. 

The  incision  to  reach  the  appendix  or  cjecum  should  be  from  two  to 
four  inches  long,  and  a  little  outside  of  the  right  semi-lunar  line  with  its 
lower  extremity  about  an  inch  above  Poupart's  ligament.  Every  pre- 
caution should  be  taken,  by  surrounding  the  field  of  operation  by  flat 
sponges,  to  keep  the  pus  from  the  general  peritoneal  cavity.  The  appen- 
dix will  be  found  at  the  bottom  perforated,  gangrenous,  or  inflamed. 

A  silk  ligature  should  be  tied  around  its  base,  after  which  the  appendix 
should  be  excised.  Its  stump  may  be  pushed  into  the  wall  of  the  ctecum 
in  such  a  manner  as  to  invaginate  it,  though  this  is  not  an  essential.  If 
the  dimple  made  by  invagination  of  the  stump  left  after  removal  of  the 
appendix  is  a  large  one,  the  serous  covering  of  the  cajcum  may  be  drawn 
over  the  stum})  by  Lembert  sutures  of  catgut. 

If  general  peritonitis  exists  the  peritoneal  cavity  must  be  washed  out 
and  drainage-tubes  inserted.  In  some  cases  it  will  be  better  not  to  attempt 
to  complete  the  operation  in  this  manner,  but  to  be  satisfied  with  thor- 
oughly laying  open  the  part  and  making  provision  for  thorough  disinfec- 
tion and  tlrainage. 

If  an  opening  be  found  in  the  csecum  or  colon  instead  of  in  the  appen- 
dix, it  should  be  closed  by  drawing  the  serous  covering  over  it  by  Lem- 
bert sutures,  as  in  the  case  of  ap})endix  excision. 

The  operation  of  removing  the  appendix  during  health  is  simple.  The 
stump  should  be  invaginated  and  the  peritoneum  of  the  caecum  drawn 
over  it. 

Colotomy. 

"When  an  artificial  opening  into  the  colon  is  established  for  the  purpose 
of  giving  exit  to  the  feces,  the  operation  is  termed  colotomy,  though,  as 
previously  stated,  colostomy  would  be  the  more  strictly  accurate  terra. 
A  new  anus  may  be  made  upon  either  side,  and  in  the  fumbar  region  or 
in  the  groin  ;  the  former  is  called  lumbar  colotomy,  the  latter  inguinal 
colotomy.  The  term  laparo-colotomy  would  be  better  for  the  last  named, 
since  at  times  the  artificial  anus  is  made  in  the  median  line  between  it 
and  the  groin.     The  transverse  colon  is  not  often  opened,  the  operation 


DISEASES    AND    INJURIES    OF    THE    INTESTINES.       597 

being  usually  done  upon  the  sigmoid  flexure  or  csecum,  as  would  be  sup- 
posed from  the  fact  that  the  loin  or  the  inguinal  region  is  usually  the 
place  elected  for  operation. 

Colotomy  is  performed  for  the  relief  of  imperforate  anus,  for  stricture 
of  the  rectum  to  afford  an  exit  for  the  feces,  and  in  ulceration  of  the 
rectum  and  recto-vesical  fistule  in  order  to  put  the  rectum  at  rest. 

Lumbar  colotomy,  often  called  colotomy  by  Amussat's  method,  is  ac- 
complished by  making  an  incision  in  the  loin.  The  colon  is  then  opened 
at  the  place  where  it  is  not  covered  with  peritoneum,  but  is  attached  to 
the  posterior  abdominal  wall  by  loose  cellular  tissue.  The  patient  is 
placed  in  the  prone  position  with  the  side  to  be  operated  upon  elevated  by 
means  of  a  hair  pillow  placed  under  the  belly.  This  makes  the  loin 
prominent.  The  anatomical  position  of  the  colon  is  half  an  inch  behind 
a  vertical  line  drawn  upward  from  the  middle  of  the  crest  of  the  ilium. 
The  incision  is  from  two  to  four  inches  long  and  is  made  midway  between 
the  lower  rib  and  the  crest  of  the  ilium  with  its  centre  over  the  colon, 
the  position  of  which  has  previously  been  marked  on  the  skin.  The  inci- 
sion is  made  obliquely  downward  and  outward,  which  makes  it  nearly 
parallel  to  the  ribs.  The  dissection  is  carried  toward  the  abdomen  until 
the  lumbar  fascia  and  the  edge  of  the  quadrate  muscle  is  reached.  The 
former  is  divided  and  the  edge  of  the  latter  may  be  incised  if  necessary 
to  get  room.  By  tearing  through  the  transversalis  muscle  and  fascia  the 
colon  is  found  in  the  line  previously  marked  on  the  skin,  a  little  in  front 
of  the  border  of  the  quadrate  muscle.  It  is  recognized  by  the  feces, 
which  can  be  felt  in  it,  or  by  the  longitudinal  bands  of  fibrous  tissue 
which  characterize  the  great  intestine.  If  there  is  not  an  impassable  stric- 
ture of  the  rectum  present  the  intestine  may  be  distended  with  air  by 
means  of  an  ordinary  syringe,  the  nozzle  of  which  has  been  passed 
through  a  plug  fitting  the  anus.  This  distention  may  be  a  great  aid  to  the 
recognition  of  the  colon.  It  is  often  seen  distinctly,  however,  without 
such  assistance.  The  nozzle  of  the  syringe  may  be  passed  through  the 
centre  of  a  roller  bandage  made  conical.  This  makes  an  exceedingly 
good  plug  to  prevent  escape  of  the  air  pumped  into  the  rectum  by  the 
syringe. 

Care  must  be  taken  that  the  peritoneum  bulging  into  the  w^ound  be  not 
mistaken  for  the  colon.  If  the  peritoneum  should  be  unwittingly  punc- 
tured, the  edges  of  this  serous  membrane  should  be  held  together  by 
means  of  one  or  two  hemostatic  forceps,  and  ligatures  of  catgut  or  silk 
tied  around  the  opening. 

The  operation  is  performed  on  the  right  side  if  the  obstruction  is  above 
the  sigmoid  flexure.  A  curved  needle  should  be  passed  into  the  wall  of  the 
colon  and  a  suture  carried  through  in  order  to  have  the  ends  of  the  suture 
for  drawing  the  gut  up  to  the  surface  of  the  wound.  The  colon  is  then 
carefully  stitched  fast  to  the  edges  of  the  wound  and  opened  at  once,  or 
after  the  lapse  of  two  or  three  days  when  it  has  become  adherent.  The 
latter  method  is  safer,  since  the  possibility  of  feces  escaping  into  the  tissues 
around  the  colon  is  avoided.  The  opening  may  be  made  without  anaes- 
thesia, since  the  intestinal  tissue  is  not  very  sensitive.  In  either  event 
th.e  deep  portion  of  the  wound  should  be  carefully  sutured  and  drainage- 
tubes  put  in  both  the  upper  and  lower  extremities  of  the  deep  wound. 

Absorbent  dressings  to  catch  the  discharging  feces  should  be  applied 
and  frequently  changed.  This  is  especially  necessary  if  an  artificial  anus 
has  been  made  at  the  time  of  the  original  operation.  Some  prolapse  of 
the  mucous  membrane  often  occurs  in  cases  of  colotomy,  but  it  does  not 


598  DISEASES    OF    THE    ABDOMEX    AND    PELVIS. 

usually  become  very  marked.  Indeed,  an  artificial  anus  often  shows  a 
tendency  to  contract,  and  dilatation  is  required  to  keep  it  sufficiently 
jiatulous. 

The  patient  usually  has  no  great  inconvenience  from  an  artificial  anus 
and  soon  learns  to  dress  it  so  as  to  catch  any  fecal  matter  which  may 
escaj)e  at  inconvenient  times.  Absorbent  pads  are  often  more  comfort- 
able than  any  form  of  plug  or  receptacle  made  by  instrument-makers.  A 
portion  of  the  feces  may  in  certain  cases  pass  beyond  the  opening  and  get 
into  the  bowel  below.  This  is  due  to  the  fact  that  when  the  intestine  was 
brought  to  the  surface  it  was  not  sufficiently  bent  upon  itself  to  make  a 
spur  or  partition.  Various  operations  have  been  devised  to  prevent  or 
remedy  this  occurrence.  In  making  tlie  artificial  anus  the  surgeon  should 
endeavor  to  secure  a  good  spur  between  the  upper  and  lower  portions  of 
the  tube. 

Laparo-colotomy. 

When  an  artificial  anus  is  established  in  the  inguinal  region  (often 
called  Littre's  method),  and  when  the  incision  and  the  abdominal  opening 
is  made  in  the  middle  line,  the  operation  is  called  laparo-colotomy.  This 
operation  has  some  advantages  over  lumbar  colotomy.  The  bowel  is 
more  easily  found,  and  a  more  accurate  exploration  of  the  condition  for 
which  the  operation  was  done  is  possible.  These  advantages  are  partic- 
ularlv  marked  if  the  median  instead  of  the  inguinal  iucisicm  is  made.  If 
it  is  found  that  an  opening  in  the  descending  portion  of  the  colon  w'ould 
not  be  serviceable  in  relieving  the  obstruction,  it  is  possible  to  make  at 
once  an  opening  in  the  ascending  colon.  This  has  distinct  advantages 
over  the  lumbar  incision,  in  which,  of  course,  the  large  bowel  can  only 
be  opened  upon  the  side  corresponding  with  the  external  wound.  The 
anterior  operation,  moreover,  is  less  serious  and  troublesome  in  its  perform- 
ance than  the  lumbar  method,  and  puts  the  artificial  anus  at  a  place 
where  it  can  be  easily  attended  to  by  the  patient. 

Laparo-colotomy,  if  done  in  the  inguinal  region,  requires  a  two-inch 
incision,  which  should  be  parallel  to  Poupart's  ligament,  beginning  an 
inch  inside  of  the  anterior-superior  spinous  process  of  the  ilium.  It 
should  be  situated  a  short  distance  above  Poupart's  ligament.  After  the 
parietal  peritoneum  has  been  sutured  to  the  skin  the  sigmoid  flexure  is 
drawn  through  the  opening,  and  a  piece  with  a  rather  long  mesentery 
selected.  Two  silk  sutures  are  then  carried  through  the  mesentery  close 
to  the  bowel,  but  on  opposite  sides,  and  their  ends  brought  out  through 
the  skin  by  means  of  a  needle.  These  ligatures  or  sutures  should  be 
about  three  inches  apart.  The  lower  ligature  is  attached  to  the  skin 
nearer  the  end  of  the  incision  than  is  the  upper  one.  These  ligatures 
when  tied  hold  the  bowel  against  the  inner  aspect  of  the  abdominal 
wound.  The  protruding  portion  of  intestine  is  then  sutured  with  care  to 
the  edges  of  the  wound.  The  ligatures  retain  the  gut  in  a  flexed  condi- 
tion so  that  a  spur  is  made  between  the  upper  and  lower  portion  of  the 
tube.  Antiseptic  dressings  are  then  applied,  and  if  three  days  have 
elapsed  before  the  opening  is  made  into  the  colon,  inflammatory  adhesion 
between  the  intestine  and  the  belly  wall  will  have  occurred.  Incision  is 
then  made  into  the  bowel  without  anaesthesia. 

The  intestinal  wound  should  correspond  with  the  long  diameter  of  the 
bowel  and  should  be  about  half  an  inch  in  length.  The  edges  of  the 
wound  may  subsequently  be  trimmed  away  so  as  to  make  a  good  sized 


DISEASES    AND    INJURIES    OF    THE    INTESTINES.       599 

opening.     The  operation  in  the  median  line  is  conducted  on  the  same 
principles. 

Resection  of  the  Intestine. 

Resection  or  excision  of  intestine  is  the  removal  of  a  portion  of  the 
bowel ;  and  is  often  followed  by  immediate  suturing  of  the  ends  of  the 
tube  thus  left.  The  word  enterectomy  is  often  used  to  include  operations 
of  this  sort  upon  the  large  as  well  as  upon  the  small  intestine.  Strictly, 
it  should  be  emj)loyed  only  for  resection  of  the  small  intestine,  while 
colectomy  should  be  used  when  a  portion  of  the  large  bowel  is  cut  away. 
Resection  of  the  intestine  is  adopted  in  gunshot  and  in  stab  wounds,  when 
the  bowel  is  too  much  injured  to  admit  of  simple  suturing ;  in  malignant 
and  other  strictures  of  the  bowel ;  in  gangrene  of  the  intestine  ;  and  in 
some  cases  of  incurable  artificial  anus.  After  gangrenous  hernia  resection 
may  be  necessary  at  the  inguinal  canal.  At  other  times  it  is  done  after 
making  a  preliminary  abdominal  section,  which  is  usually  made  in  the 
median  line. 

The  operation  is  divided  into'  three  stages :  Separation  of  the  bowel, 
excision  of  the  intestinal  tube,  and  suturing  together  of  the  cut  ends. 
Adhesions  between  the  portion  about  to  be  excised  and  other  intestinal 
loops,  or  between  it  and  the  solid  viscera,  are  a  contra-indication  to  ope- 
ration. The  portion  to  be  operated  upon  must  be  movable  enough  to  be 
brought  to  the  surface  of  the  abdominal  wound  in  order  to  permit  the 
necessary  manipulation. 

In  performing  resection  of  the  bowel  the  removal  must  include  sufficient 
of  the  intestinal  tube  to  reach  healthy  tissue  above  and  below  the  seat  of 
the  disease.  The  intestinal  contents,  whether  feces  or  gas,  should  be 
pressed  out  of  the  portion  of  the  tube  to  be  operated  upon,  and  clamps 
should  be  placed  above  and  below  the  field  of  operation. 

Fig.  374. 


Clamp  for  resection  of  bowel. 

The  bowel  is  then  cut  loose  from  the  mesentery  and  the  clamps  succes- 
sively released  in  order  that  the  feces  and  gas  retained  beyond  the  clamp 
may  be  allowed  to  escape.  In  cases  of  obstruction  the  amount  of  mate- 
rial which  will  thus  flow  out  is,  of  course,  great.  Much  care  should  be 
taken  that  this  material  does  not  come  in  contact  with  the  general  peri- 
toneal cavity,  which  may  be  separated  from  the  field  of  operation  by 
packing  large,  flat  sponges  into  the  abdominal  wound.  The  portion  of 
gut  which  the  surgeon  is  about  to  cut  ofi"  may,  after  it  is  detached  at  the 
lower  end,  be  used  to  conduct  away  this  accumulation  of  fecal  matter  into 
a  vessel  held  alongside  the  patient.  After  the  portion  to  be  excised  has 
been  separated  from  the  mesentery  some  surgeons  prefer  to  cut  out  of  the 
mesentery  a  V-shaped  piece  in  order  to  get  rid  of  the  redundant  mesen- 
teric tissue.  If  this  is  done  it  is  necessary  to  unite  carefully  the  edges  of 
the  mesentery  by  overlapping  them  and  applying  sutures.  It  is  not  neces- 
sary, however,  to  make  this  V-shaped  incision,  since  the  redundant  mesen- 
teric tissue  can  be  folded  up  by  means  of  sutures  and  attached  behind 


000 


DISEASES    OF    THE    ABDOMEN    AND    PELVIS, 


the  junction  of  the  two  ends  of  the  intestine  after  they  have  been  sewed 
together.     This  adds  somewhat  to  the  strength  of  the  union. 

IJleeding  from  the  small  vessels  of  the  intestinal  wall  will  follow  ex- 
cision of  the  diseased  portion,  and  should  be  stopped  by  means  of  fine 
ligatures.  Care  must  be  taken  not  to  devitalize  the  intestinal  coats  bv 
compression  of  these  vessels  with  large  hiemostatic  forceps,  which  grasp 
a  great  deal  of  tissue.  Small-pointed  arterial  forceps  shculd  be  used,  and 
only  the  vessels  enclosed  in  their  grasp. 

The  most  important  and  tedious  step  in  enterectomy  is  stitching 
together  the  cut  tube,  which  must  be  well  done  in  order  to  prevent  ex- 
travasation of  feces  into  the  general  peritoneal  cavity  after  the  abdominal 
wound  has  been  closed.  Fine  twisted  silk  makes  the  best  sutures.  They 
should  be  carried  through  the  peritoneal  and  muscular  coats,  but  should 
never  perforate  the  mucous  membrane  so  as  to  enter  the  lumen  of  the  bow'el. 
If  any  sutures  are  inserted  for  the  purpose  of  uniting  the  mucous  mem- 
l)rane.  they  must  be  tied  on  the  inside  of  the  gut,  and  not  come  through 
to  the  peritoneal  surface.     The  Lembert  suture  is  probably  the  best  form 


Fk;.  .375. 


Fig.  .376. 


Fig.  .377. 


Continuous  suture 
applied  to  intestine. 


Lembert's  suture.     (Bryast.) 


Quilt  suture. 


to  use  after  resection  of  the  intestinal  tube.  After  the  insertion  of  these 
sutures  the  continued  suture  may  be  used  as  an  additional  means  of  sup- 
port at  any  dangerously  weak  spot  in  the  bond  of  union.  The  quilt  suture 
is  another  satisfactory  method. 

The  sutures  may  be  inserted  while  the  clamps  are  upon  the  intestines,  or 
some  liquefiable  cylinder,  such  as  a  long  plug  of  cocoa-butter,  may  be 
in.serted  into  the  cut  ends  of  the  tube,  and  the  sutures  placed  while  the 
bowel  is  thus  distended.  A  rubber  bag,  which  can  be  distended  with  air, 
will  answer  the  same  purpose.  Such  devices  are,  however,  not  absolutely 
necessary. 

The  least  point  of  leakage  at  the  place  where  the  enterorrhaphy  is  made 
will,  of  course,  destroy  the  success  of  the  operation,  and  will  probably 
give  rise  to  fatal  peritonitis.  In  order  to  make  the  point  of  union  still 
more  perfect,  Senn  has  proposed  taking  grafts  of  omentum  and  applying 
them  along  the  suture  line.  He  cuts  out  a  small  strip  of  omentum  about 
two  inches  in  width,  and  long  enough  to  go  around  the  gut.  He  keeps 
this  in  a  warm  anti.septic  solution  (sublimate,  1  to  2000), until  he  is  ready 
to  apj)ly  it  around  the  junction  as  a  sort  of  collar.  The  ends  of  the  graft 
are  stitched  to  the  mesentery  ;  and  as  the  graft  is  aseptic  it  becomes  united 
to  the  gut  at  the  seat  of  operation.  To  make  the  graft  more  readily 
adhere,  the  peritoneal  surface  of  the  bowel  may  be  slightly  scratched  with 
a  needle  point  to  cause  rapid  exudation  of  lymph. 


DISEASES    AND    INJURIES    OF    THE    INTESTINES. 


601 


The  bowel  thus  prepared  and  sutured  is  returned  into  the  abdominal 
cavity,  for  these  manipulations  have  been  done,  of  course,  outside  the  ab- 
domen, and  the  wound  closed  in  the  ordinary  manner.  If  there  is  any 
doubt  about  the  perfection  of  the  enterorrhaphy,  it  is  well  to  stitch  the 
repaired  gut  to  the  edge  of  the  wound.  Then,  if  one  of  the  sutures  be- 
comes untied,  or  a  leak  occurs,  it  will  be  at  once  discovered  ;  when  opening 
of  the  abdomen,  irrigation  and  drainage  may  be  promptly  instituted. 


Fig.  378. 


Drawing  to  show  method  of  suturing  bowel  after  resection.  (Geeio  Smith.) 

If  it  is  impossible  to  complete  the  resection  in  a  case  where  this  has 
been  attempted,  an  artificial  anus  must  be  made  by  attaching  the  wounded 
intestine  to  the  abdominal  wall.  If  colectomy  is  anticipated  wdien  the 
operation  is  begun,  it  may  be  better  to  make  a  lateral  rather  than  a  median 
laparotomy.     After  such  lateral  opening  has  been  made,  which  may  be 


002 


DISEASES    OF    THE     ABDOMEN    AND    PELVIS. 


small  for  exploratory  purposes,  it  is  not  improper  to  do  the  operation 
through  another  incision,  made  in  the  median  line,  if  the  lateral  one  is 
found  disadvantageous. 

Intestinal  Anastomosis. 

This  term  signifies  the  construction  of  a  permanent  orifice  between  two 
portions  of  gut,  so  as  to  exclude  the  intervening  portion  from  conducting 
the  feces.  When  intestinal  anastomosis  is  established  between  the 
jejunum  and  the  ileum,  the  term  jejuno-ileostomy  is  used.  Ilco-colos- 
tomy  is  the  construction  of  an  orifice  between  the  ileum  and  the  colon, 
while  gastro-enterostomy  is  applied  to  the  creation  of  an  opening  between 
the  stomach  and  a  portion  of  the  small  intestine. 

Intestinal  anastomosis  is  indicated  in  obstruction  of  the  intestines  and 
in  such  malignant  strictures  as  cannot  be  overcome  or  removed  with 
safety.  Apposition  of  the  tubes  between  which  the  orifice  is  to  be  made 
is  maintained  by  decalcified  bone  plates  with  central  openings,  or  by  ellip- 
tical rings  of  catgut  or  rubber.  After  these  have  served  their  purpose  in 
keeping  the  serous  surfaces  in  contact,  they  are  either  dissolved  in  the 


Fig.  379. 


Diagram  of  method  of  using  decalcified  bone  plates  of  Seun.  (Greig  Smith. 

intestinal  fluids,  or,  as  in  the  case  of  rubber  rings,  pass  through  the  bowels 
and  escape  from  the  anus  undigested.  In  using  the  rubber  rings  it 
is  customary  to  cut  them  at  one  point  and  unite  the  cut  ends  with 
catgut,  which  becomes  dissolved  and  allows  the  rings  to  pass  through  the 
l)owel  straightened  out  and  not  as  a  cylinder.  The  use  of  plates  or  rings 
adds  greatly  to  the  safety  of  the  operation  of  intestinal  anastomosis.  In 
suturing  the  apposed  tubes  a  preliminary  scratching  of  the  peritoneum 
Avith  a  needle  point  will  add  to  the  certainty  of  the  results. 

Spring  clamps  are  put  upon  the  intestine  above  and  below  the  seat  of 


DISEASES    AND    INJURIES    OF    THE    LIVER.  603 

operation  after  the  intestinal  contents  have  been  squeezed  out,  as  in  resec- 
tion. A  point  must  be  selected  which  will  not  cause  dragging  upon  the 
mesentery  or  the  bowel  when  the  surfaces  are  put  together.  An  incision 
from  two  to.  two  and  a  half  inches  long  is  made  in  each  portion  of  the 
gut,  corresponding  with  its  long  diameter,  and  on  the  side  opposite  to  the 
mesentery.  Through  these  are  passed  into  the  lumen  of  the  bowel  the 
catgut  or  rubber  rings,  to  each  of  which  four  sutures  are  attached  or 
fastened.  The  lateral  threads  are  carried  through  all  the  coats  of  the 
intestinal  wall,  w^hile  the  threads  at  the  end  of  the  elliptical  rings  come 
through  the  wound.  The  ends  of  the  corresponding  threads  are  then 
tied  upon  the  peritoneal  surfaces  of  the  apposed  coils  of  gut.  The  open- 
ing in  the  centre  of  the  ring  prevents  obstruction  of  the  intestinal  flow 
from  one  coil  to  another. 

Intestinal  anastomosis  may  be  employed  instead  of  a  circular  suture 
after  resection.  In  this  case  the  two  cylinders  are  laid  side  by  side,  and 
the  walls  at  the  cut  ends  are  turned  in  and  sutured  in  a  straight  line 
across  the  extremity.  After  this  a  new  opening  is  made  and  the  apposi- 
tion rings  adjusted. 

Fio.  380. 


WALL  OF 

INTESTINE 

TURNED  IN    AND" 

SECURED   BY      ;! 

LEMBERT  STITCHES\-d  INTESTINE 

Diagram  showing  position  of  decalcified  bone  plates  in  intestinal  anastoMosis  after 
resection  of  bowel. 

The  mere  slit,  made  for  the  insertion  of  the  rings  and  for  the  new  orifice 
between  the  intestinal  tubes,  seems  at  times  to  give  too  small  an  orifice  for 
the  ready  passage  of  feces.  It  probably  contracts  during  cicatrization. 
It  is  possible  that  trimming  away  the  edges  of  the  intestinal  incision,  so 
as  to  make  an  elliptical  hole  in  each  cylinder  of  gut  will  obviate  this 
condition. 

Diseases  and  Injuries  of  the  Liver. 

Laceration  and  other  wounds  of  the  liver  may  be  indicated  by  local 
pain,  jaundice,  clay-colored  stools,  bilious  vomiting  and  sugar  in  the  urine. 
The  symptoms  vary  with  the  locality  and  extent  of  the  injury.  The 
treatment  is  immediate  abdominal  section  with  suturing  of  the  liver,  and 
ligation  or  the  use  of  the  actual  cautery  to  stop  bleeding. 

Abscess  of  the  liver  is  especially  frequent  in  tropical  countries,  but  is 
also  met  with  elsewhere.  The  suppurative  process  not  infrequently  gives 
rise  to  multiple  abscesses.  The  pus  which  may  originally  be  formed  at  some 
distance  from  the  surface  of  the  liver,  may  be  evacuated  spontaneously 
into  the  chest,  abdomen,  or  bowel,  or  upon  the  exterior  of  the  body.    The 


004  DISEASES    OF    THK     AUDOMEN    AND    PELVIS. 

symptoms  are  rather  negative,  but  increased  hepatic  dulness  associated 
with  pain  and  tenderness  is  suggestive  of  the  j)ossibility  of  abscess. 

Hychitid  cysts  give  rise  to  symptoms  similar  to  abscess.  The  peculiar 
fremitus,  which  is  so  characteristic  of  the  presence  of  this  form  of  cyst, 
is  often  absent  in  hepatic  hydatid  cysts.  Suppuration  of  these  cysts  is 
not  uncommon.  Then  the  symptoms  are  identical  with  abscess  from 
other  causes.  Fluctuation  is  only  perceptible  in  abscess  and  hydatid  dis- 
ea.se  when  the  collection  is  large  and  near  the  surface. 

The  best  treatment  of  hepatic  abscess  is  laparotomy  followed  by  incision 
of  the  abscess  (hepatotomv)  and  drainage  by  a  tube  left  in  the  wound. 
It  is  unwise  to  wait  for  the  occurrence  of  adhesions  between  the  liver  and 
the  belly  wall  with  the  idea  of  incising  or  aspirating  the  abscess  through 
the  parietes,  because  fatal  rupture  may  take  place  before  adhesion  occurs. 
Moreover,  there  is  often  no  means  by  which  the  surgeon  can  be  sure  of 
the  existence  of  adhesion  between  the  liver  and  abdominal  wall.  An 
abdominal  incision  should  be  made  over  the  tumor  if  there  be  one.  If 
adhesions  of  the  liver  to  the  belly  wall  are  found  to  exist  after  this 
incision  has  been  made,  it  is  wise  to  close  the  exploratory  wound  and  to 
open  the  abscass  by  a  new  cutaneous  cut  carried  through  the  adherent 
area.  In  other  cases  the  abscess  is  punctured,  a  finger  inserted,  and  the 
liver  drawn  up  to  the  abdominal  wound  in  order  that  the  abscess  cavity 
may  be  evacuated  without  pus  escaping  into  the  peritoneal  cavity.  When 
this  abscess  has  been  emptied  the  finger  should  explore  its  interior  and 
rupture  any  neighboring  abscesses,  so  that  all  will  empty  themselves 
through  the  original  opening  in  the  liver.  A  weak  antiseptic  solution  is 
used  to  wash  out  the  suppurating  cavity,  after  which  the  edges  of  the 
abscess  wound  are  stitched  to  the  skin,  and  a  large  drainage-tube  of 
rubber  inserted.  The  j)eritoneal  cavity  should  be  thoroughly  washed  out 
with  warm  sterilized  water  if  it  has  been  soiled,  and  the  usual  dressings 
applied.  Pus  should  be  sucked  out  of  the  abscess  cavity  by  means  of  a 
syringe  every  day,  and  possibly  irrigated  with  a  weak  antiseptic  fluid. 
Hydatid  cysts  should  be  treated  by  incision  and  suturing  to  the  belly 
wall  in  the  same  manner  as  abscesses. 


Malignant  Diseases  of  the  Liver. 

A  malignant  tumor  of  the  liver,  if  single,  may  be  removed  by  lapar- 
otomy, it  is  unusual,  however,  to  find  a  single  malignant  nodule,  since 
the  symptoms  are  scarcely  prominent  enough  to  suggest  exploratory  lapar- 
otomy until  the  disease  has  advanced  far  enough  to  cause  multiple  tumors 
or  large  and  immovable  growths. 


D1.SEASE.S  AND  Injuries  of  the  Gall-bladder. 

Rupture  and  wounds  of  the  gall-bladder,  because  of  the  inflammation 
caused  thereby,  are  nearly  always  fatal  unless  treated  by  surgical  means. 
The  exudation  of  plastic  lymph  as  a  concomitant  of  a  localized  peritonitis, 
may  occasionally  circumscribe  the  inflammation  and  thereby  prolong  life, 
or  even  prevent  the  fatal  issue. 

The  treatment,  however,  is  clear.  It  consists  in  opening  the  abdomen 
and  stitching  the  edges  of  the  wound  in  the  gall-bladder  to  the  skin,  as  in 
the  ordinary  operation  of  cholecystotomy. 


DISEASES    AND    INJUEIES    OF    THE    GALL-BLADDER,      605 


Choleeystotomy. 

Cholecystotomy,  or  incision  of  the  gall-bladder,  is  performed  for  the  ex- 
traction of  gall-stones,  for  the  treatment  of  dropsy  and  empyema  of  the 
gall-bladder,  for  obstruction  of  the  common  bile-duct,  and  in  cases  of  rup- 
ture or  wounds  of  the  gall-bladder.  Gall-stones  give  rise  to  attacks  of 
hepatic  colic,  the  pain  of  which  is  often  agonizing.  Inflammation,  suppu- 
ration, and  gangrene  of  the  gall-bladder  may  occur  as  a  result  of  the 
presence  of  stones  in  the  bladder,  while  their  passage  into  and  arrest  in  the 
biliary  passages  may  cause  obstruction  of  the  cystic,  hepatic,  or  common 
bile-duct.  Such  obstruction,  if  involving  only  the  cystic  duct,  gives  rise 
to  local  symptoms,  such  as  distention  of  the  gall-bladder,  followed,  per- 
haps, by  inflammation,  gangrene,  and  the  occurrence  of  biliary  fistule. 
By  sloughing  of  the  wall  of  the  gall-bladder  and  surrounding  tissues, 
gall-stones  may  pass  into  the  lungs,  bowels,  and  peritoneal  cavity.  Fatal 
peritonitis  is  a  complication  which  may  be  thus  excited.  If  gall-stones 
become  impacted  in  the  common  bile-duct,  jaundice  and  chol^emia  result 
in  addition  to  local  pain  and  inflammation. 

Stones  lying  in  the  gall-bladder  and  not  becoming  entangled  in  the 
duct,  may  give  rise  to  no  special  symptoms  and  remain  unnoticed  for 
years. 

Dropsy,  or  empyema,  of  the  gall-bladder  is  usually  due  to  stones,  but 
may  be  caused  by  hydatids  or  intestinal  worms  plugging  the  duct,  or  to 
pressure  from  some  tumor  connected  with  the  neighboring  viscera.  The 
distention  may  be  so  great  as  to  cause  the  bladder  to  fill  nearly  the  entire 
abdomen.     In  such  cases  the  walls  are  apt  to  be  thinned. 

Stricture  from  inflammation  of  the  mucous  membrane  of  the  duct  may 
give  rise  to  purulent  distention  of  the  gall-bladder.  Thickening,  ulcera- 
tion, and  perforation  of  the  walls  may  occur  as  a  result  of  suppurative 
inflammation  within  the  gall-bladder. 

The  diagnosis  of  these  pathological  changes  in  the  gall-bladder  is  made 
by  the  existence  of  a  tumor  in  the  right  hypochondriac  region.  It  may 
be  fluctuating,  or  so  tensely  distended  as  to  be  hard.  It  may  be  pear- 
shaped  or  globular,  but  usually  increases  in  size  in  an  oblique  direction 
from  the  hypochondrium  toward  the  umbilicus.  Jaundice  is  frequently 
absent,  because  the  common  bile-duct  is  unobstructed. 

The  diagnosis  between  distention  of  the  gall-bladder,  cystic  tumor  of 
the  kidney,  movable  kidney,  and  inflammation  about  the  pylorus  or  head 
of  the  pancreas  is  difiicult. 

The  operation  of  cholecystotomy  is  demanded  in  wounds,  dropsy,  and 
empyema  of  the  gall-bladder.  It  is  often  required  in  cases  of  gall-stones, 
but  in  this  condition  should  not  be  performed  until  the  frequency  of 
hepatic  colic,  the  exhaustion  of  the  patient  from  cholsemia,  or  the  evident 
existence  of  a  greatly  distended  bladder  filled  with  stones  indicates  its 
necessity. 

The  operation  is  more  successful  in  cases  in  Avhich  jaundice  is  not 
present,  because  bile  in  the  blood  (chokemia )  depresses  the  patient's  forces 
and  renders  the  bleeding  more  profuse.  The  operation,  however,  must 
often  be  done  in  cases  where  jaundice  exists.  Opening  the  gall  bladder 
and  simply  stitching  its  wall  to  the  abdominal  parietes  is  the  operation 
called  cholecystotomy.  Kemoval  of  gall  stones  after  such  an  incision  is 
cholelithotomv,  while,  if  it  is  necessary  to  crush  the  stones  before  remov- 
ing them,  the  procedure  is  termed  cholelithotrity. 


60G 


DISEASES    OF    THE    ABDOMEN    AND    PELVIS. 


The  incision  should  be  made  over  the  fundus  of  the  t^all  l)hi(hl(>r,  which 
corresponds  witli  the  tip  of  the  cartiUige  of  the  tenth  rili  on  the  right 
side,  or  it  may  he  made  over  the  tumor,  if  one  exists.  The  incision  should 
be  vertical.  If  the  bladder  is  greatly  distended  some  of  the  fluid  may  be 
drained  away  by  an  aspirator  before  an  incision  large  enough  to  permit 
insertion  of  a  finger  is  made.  Care  should  be  taken,  by  packing  wet 
sponges  around  the  seat  of  the  operation,  to  prevent  the  bile  flowing  into 
the  peritoneal  cavity.  The  gall-stones  should  be  removed  with  a  scoop 
or  forceps,  or  crushed  with  appropriate  forceps. 

Fig.  .-^Sl. 


Tait's  cholelithotomy  forceps. 

The  surgeon  must  recollect  that  the  walls  are  thin  and  easily  torn. 
If  laceration  occurs  it  may  be  necessary  to  remove  the  entire  bladder 
(cholecystectomy).  If  the  stone  is  immovably  fixed  in  the  duct  it  may  be 
nibbled  away  with  Tait's  forceps.  Possibly  it  may  be  broken  up  by 
thrusting  a  needle  into  it.  After  the  stones  have  been  removed,  or  the 
dropsical  fluid  or  other  contents  evacuated,  the  gall-bladder  must  be 
sutured  to  the  edges  of  the  belly  wall.  The  stitching  should  be  by  a  con- 
tinuous suture  of  silk  and  pass  through  the  skin,  peritoneum,  and  bladder 
wall. 

A  drainage-tube,  preferably  of  rubber,  should  always  be  inserted  and 
the  belly  wound  closed  around  it.  The  bile  which  flows  from  the  tube 
may  be  conducted  into  a  bottle  lying  alongside  of  the  patient.  A  piece 
of  rubber  dam  may  be  fixed  around  the  orifice  of  the  tube  so  as  to  pre- 
vent the  bile  coming  into  contact  with  the  wound,  and  a  mass  of  absorb- 
ent material  placed  over  the  orifice.  If  all  stones  have  been  removed  .so 
that  the  bile  flows  through  into  the  intestine,  the  fistule  made  by  the  ope- 
ration will  finally  close.  If  such  is  not  the  case  it  may  become  necessary 
to  make  a  permanent  opening  between  the  intestine  and  bladder  by  sub- 
sequent operation.     Such  an  operation  is  entero-cholecystostomy. 

Biliary  fi.stules  from  spontaneous  evacuation  of  the  bladder  contents 
will  not  close  unless  the  bile  is  conducted  into  the  intestine  by  this  same 


DISEASES    AND    INJURIES    OF    THE     UTERUS.  607 

operation ;  after  which  plastic  operations  upon  external  openings  may  be 
made  if  closure  does  not  take  place. 

Diseases  and  Injuries  of  the  Spleen. 

Rupture  or  wounds  of  the  spleen  should  be  treated  by  abdominal  sec- 
tion and  suturing.  When  the  damage  done  is  very  great,  removal  of  the 
spleen  (splenectomy)  maybe  demanded.  Cyst  of  the  spleen  is  to  be 
treated  by  laparotomy  and  incision  followed  by  drainage.  The  operation 
of  incision  into  the  spleen  is  termed  splenotomy.  Excision  of  the  spleen 
or  splenectomy,  may  be  required  in  some  cases  of  movable  spleen,  in 
hypertrophy  of  the  spleen,  when  it  is  not  leucocyth^emic,  and  in  tumors. 

The  operation  is  performed  by  an  incision  through  the  left  semilunar 
line.  The  attachments  of  the  organ  are  divided  and  ligated,  clamps  in 
some  instances  being  required  before  the  adhesions  are  cut.  Hemorrhage 
is  the  great  danger,  hence  it  is  necessary  that  each  stump  should  be  tied 
separately. 

Diseases  and  Injuries  of  the  Pancreas. 

Abscesses  and  cysts  of  the  pancreas  should  be  treated  by  laparotomy, 
incision  of  the  abscess  or  cyst,  and  the  establishment  of  a  fistule  by  at- 
taching the  edge  of  the  sac  to  the  abdominal  incision.  This  is  done 
because  of  the  necessity  of  providing  for  the  escape  of  the  pancreatic  fluid, 
which  would  otherwise  flow  into  the  peritoneal  cavity.  The  incision 
should  be  made  over  the  tumor. 


Diseases  and  Injuries  of  the  Uterus  and  its  Appendages. 

Injuries  of  the  abdomen  seldom  involve  the  uterus  unless  it  be  pregnant, 
or  in  cases  where  the  injury  is  so  extreme  as  to  do  damage  to  many  of  the 
abdominal  and  pelvic  organs.  A  pregnant  uterus  has  by  error  been 
tapped  for  abdominal  dropsy.  The  wound  in  such  cases  is  apt  to  cause 
abortion.  If  serious  symptoms  or  peritonitis  should  ai'ise  from  this,  or  any 
other  uterine  injury,  abdominal  section  should  be  performed,  and  the  con- 
dition found  treated  on  general  principles,  such  as  suturing  of  the  wound, 
irrigating  the  peritoneal  cavity,  and  drainage. 

Fibro-myomatous  tumors  of  the  uterus  are  quite  common  growths, 
especially  in  the  negro.  They  are  often  called  fibroids  because  they  re- 
semble fibromas.  They  are,  as  a  rule,  however,  largely  myomatous  in 
their  histological  features ;  and  are  the  most  common  of  uterine  tumors. 
If  they  develop  beneath  the  peritoneum  they  are  called  subserous,  or  sub- 
peritoneal fibro-myomas ;  if  under  the  mucous  membrane  of  the  uterus, 
submucous  fibro-myomas ;  while  those  developing  within  the  substance  of 
the  uterus  are  called  interstitial  or  intramural  tumors. 

These  tumors  are  interesting,  surgically,  particularly  when  they  are 
developed  under  the  peritoneum,  as  then  they  may  be  confounded  with 
other  growths  until  the  abdomen  is  opened.  A  uterine  fibro-myoma  gives 
rise  to  pain,  uterine  hemorrhage,  and  a  hard  iri'egular  tumor,  which  can 
often  be  felt  through  the  abdominal  wall. 

Ergot  is  given  for  the  relief  of  the  hemorrhage  and  to  cause  uterine 
contraction,  by  w^hich  it  is  hoped  the  growth  may  be  gradually  forced 
through  the  uterine  cavity  toward  the  vagina,  where  it  is  more  accessible 


008  DISEASES    OF    THE    ABDOMEN    AND    PELVIS. 

to  removal.  The  submucous  form  sometimes  has  quite  a  long  pedicle.  If 
this  is  the  case  the  growth  may  be  removed  by  the  ecraseur,  introduced 
through  the  vagina.  Sessile  growths  of  this  sort  are  treated  by  scraping 
away  with  a  spoon  having  a  saw-like  edge,  after  a  preliminary  dilatation 
or  incision  of  the  os  has  been  performed,  so  as  to  facilitate  the  intra-uterine 
manipulation.  The  intra-mural  fibro-myomas  may  also,  at  times,  be 
enucleated  by  scraping  or  incising  the  internal  uterine  wall  after  dilatation 
or  incision  of  the  os. 

Subserous  tumors  are  amenable  to  operative  treatment  only  by  abdom- 
inal section.  The  growth  may  then,  perhaps,  be  enucleated  from  the  uterine 
tissue;  or  the  uterus,  if  occupied  by  enormous  or  numerous  growths,  ex- 
tirpated ( hysterectomy). 

Apostoli  and  others  have  earnestly  advocated  the  treatment  of  these 
uterine  tumors  by  the  application  of  galvanism.  Removal  of  the  ovaries 
to  bring  on  the  menopause,  and  thereby  stop  the  monthly  congestion  of 
the  uterus,  which  aids  in  the  growth  of  these  tumors,  is  often  adopted. 

Fibro-cystic  disease  of  the  uterus  is  a  rare  condition,  and  need  not  be 
discussed. 

Malignant  disease  of  the  womb  is  most  frequently  met  in  the  neck. 
For  its  treatment,  amputation  of  the  neck  by  the  introduction  of  instru- 
ments into  the  vagina,  is  often  performed.  The  diseased  portion  may  be 
eaten  away  by  chloride  of  zinc  or  other  caustics.  The  best  treatment, 
probably,  is  removal  of  the  entire  uterus  by  the  operation  called  vaginal 
hysterectomy.  In  this  operation  the  uterus  is  pulled  down  by  toothed 
forceps,  and  an  incision  made  through  the  vaginal  mucous  membrane  in 
front  and  behind,  so  that  the  operator's  fingers  can  be  carried  into  the 
peritoneal  cavity  to  drag  down  the  entire  organ.  The  broad  ligaments 
are  then  ligated,  or  clamped  with  large  haemostatic  forceps  ;  and  the  uterus 
cut  loose.  The  peritoneum  and  mucous  tissue  at  the  top  of  the  vagina 
fall  together  as  the  uterus  is  withdrawn.  If  clamps  are  used  to  control 
the  vessels  of  the  broad  ligament,  they  are  taken  out  at  the  end  of  twenty- 
four  or  thirty-six  hours. 

Tumors  of  the  Ovary. 

Pathology. — These  growths  are  of  importance  to  tlie  surgeon,  because 
a  diagnosis  is  often  required  to  be  made  between  them  and  other  abdominal 
conditions;  and  because  the  abdomen  has  often  been  o[)ened  for  some 
other  condition,  and  an  ovarian  cyst  or  tumor  unexpectedly  found  to  be 
the  cause  of  the  symptoms. 

Ovarian  tumors  are  most  commonly  cystic,  which  may  be  unilocular, 
or  multilocular.  AVhat  are  called  unilocular  cysts  are  not  infrequently 
multilocular  cysts  with  one  cyst  greatly  developed.  Sometimes  such 
cystic  tumors  are  in  part  solid.  Tumors  which  are  dermoid  cysts,  wholly 
or  in  part,  are  not  very  rare  in  this  locality.  Tumors  of  the  broad  liga- 
ment, called  parovarian  tumors,  may  be  cystic  or  solid.  Solid  tumors  of 
the  ovary  are  rare,  and  when  found  are  usually  malignant. 

Symptoms. — Ovarian  cysts  when  small  produce  no  symptoms.  If  they 
increase  in  size  they  displace  the  uterus  forward,  or  backward,  or  laterally, 
and  probably  depress  it  a  little.  This  takes  place  when  the  tumor  is  small 
enough  to  be  contained  in  the  pelvis.  When,  from  increase  in  size,  it  rises 
into  the  abdomen,  such  changes  are  not  apt  to  be  present. 

The  symptoms  of  ovarian  tumors,  which  are  now  to  be  described,  are 
not  very  reliable,  for  similar  symptoms  may  occur  in  other  diseases,  and 


DISEASES    AND    INJUEIES    OF    THE    UTERUS. 


609 


ovarian  cysts  may  be  present  without  giving  rise  to  them  with  sufficient 
distinctness  to  be  of  value  in  diagnosis.  A  small,  rather  globular  mass, 
either  firm  or  fluctuating,  and  probably  movable,  is  found  sometimes  on 
one  or  other  side  of  the  belly.  As  it  increases  in  size  a  feeling  of  discom- 
fort, frequent  urination,  constipation,  and  oedema  of  the  limbs  from  com- 
pression of  the  veins  may  arise.  Pain  from  pressure  on  the  sacral  or 
lumbar  plexus  may  occur  and  be  reflected  down  the  legs.  Xausea,  vomit- 
ing, colicky  pains,  and,  perhaps,  diarrhoea,  are  not  improbable.  Ascites 
from  interference  with  circulation  in  the  portal  vein  is  quite  usual,  and 
hemorrhoids  from  a  similar  interference  with  the  venous  return  are  annoy- 
ing complications.  Albuminuria  also  may  be  present,  and  dyspnoea  from 
abdominal  distention  due  to  the  bulk  of  the  tumor,  and  from  the  peritoneal 
dropsy  just  mentioned,  may  be  very  distressing. 

When  the  cyst  becomes  large  enough  to  distend  the  abdomen,  greatly 
and  particularly  when  the  cyst  is  unilocular,  it  very  much  resembles  peri- 
toneal dropsy,  or  ascites  occurring  from  visceral  disease.  A  differential 
diagnosis  is  then  a  matter  of  great  importance.  Multilocular  cysts  are 
not  so  liable  to  make  a  diagnosis  difficult,  because  they  usually  have  an 
irregular  surface,  and  because  fluctuation  is  more  marked  in  some  places 
than  in  others.  The  fluctuation  wave  does  not  cross  the  whole  abdomen, 
but  is  limited  to  various  portions  of  it,  unless  one  of  the  cysts  in  the  multi- 
locular growth  is  very  much  larger  than  the  others.     A  unilocular  cyst 


Fig.  382. 


Fig.  .383. 


Diagrams  showing  development  of  areas  of  dulness  in  ascites  {Fig.  382)  and  in  ovarian 
tumor  (Fig.  383).  The  darker  shading  indicates  an  earlier  stage  of  disease.  (Gkeig 
Smith  ) 

has  a  smooth  outline,  is  elastic,  and  gives  a  fluctuation  wave  over  its 
whole  extent.  This  last  symptom  is  very  like  that  given  by  ascites. 
Dulness  on  percussion  exists  over  the  tumor  whether  it  is  unilocular  or 
multilocular.  In  ovarian  dropsy,  a  term  often  used  to  signify  an  ovarian 
cyst,  the  area  of  dulness  is  circular,  wuth  the  convexity  of  the  circle 
directed  upward  near  the  middle  line,  with  resonance  extending  downward 
upon  each  side. 

In  ascites  the  dull  area  gives  a  crescentic  line  with  the  concavity  upward, 
while  resonance  is  notably  situated  between  this  line  and  the  stomach. 
The  dulness  of  ascites  is  changed  by  turning  the  patient  on  her  side. 

'69 


610  DISEASES    OK    THE    ABDOMEN    AXD    PELVIS. 

This  does  not  take  place  in  ovarian  dropsy,  where  the  line  is  practically 
unchanged  by  such  movement.  It  should  l)e  remembered  that  wlien  an 
ovarian  cyst  is  accompanied  with  ascites,  due  to  pressure  of  the  cyst 
upon  the  venous  trunks,  there  may  be  dulness  in  the  flank,  fluctuation 
across  the  whole  abdomen,  because  of  the  complicating  ascites.  This  will 
destroy  the  outline  of  the  resonant  area  indicative  of  ovarian  cyst. 

In  ovarian  cysts  there  is  often  a  peculiar  heaping  up,  as  it  were,  in  the 
middle  line,  which  is  due  to  the  greater  distention  in  the  middle  portion 
of  the  abdomen  ;  but  in  ascites  gravity  acting  on  the  unconfined  fluid 
causes  distention  at  the  sides  of  the  abdomen  and  flattens  the  front  of 
the  belly.  In  ascites,  moreover,  there  is  apt  to  be  evidence  of  disease  ot 
the  lieart,  or  of  the  kidney,  liver,  or  some  other  abdominal  organs,  with 
jierhaps  a'dema  of  the  arms  and  face.  (Edema  of  the  legs  does  not  aid 
much,  because,  though  freijuently  occurring  in  cardiac,  renal,  and  liver 
disease,  it  also  exists  in  cystic  tumor  of  the  ovary,  from  pressure  of  the 
growth  on  the  caval  and  iliac  veins.  When  abdominal  dropsy  exists  in 
addition  to  the  ovarian  cyst,  the  diagnosis  of  a  tumor  in  addition  to  the 
ascites  may  sometimes  be  made  by  quick  and  forcible  pressure  of  the 
fingers  upon  the  abdominal  wall.  Tiie  sudden  pressure  or  tap  causes  the 
peritoneal  fluid  to  be  pushed  aside  and  the  fingers  come  abruptly  upon 
the  ovarian  cyst  or  other  growth.  This  would  not  occur  if  ascites  alone 
existed,  nor  if  a  large  ovarian  cyst  without  accompanying  ascites  were 
present.  The  fluid  of  ascites  is  usually  thin  yellow  serum.  The  fluid  of 
ovarian  cysts  is  frequently  brownish  in  appearance. 

Encvsted  dropsy  of  the  peritoneum  is  difficult  to  diagnose  from  ovarian 
cyst.  A  dift'erential  diagnosis  is  often  impossible.  Cysts  of  the  broad 
ligament  resemble  ovarian  tumors  in  their  symptoms,  and  in  their  treat- 
ment, except  that  tapping  is  sometimes  curative  in  the  former.  Ovarian 
cysts  should  seldom,  if  ever,  be  tapped,  and  then  tapping  is  not  curative. 
As  other  growths,  cysts  of  the  ovary  may  become  adherent  to  the  intes- 
tines, solid  viscera,  and  abdominal  wall.  The  presence  of  adhesions  cannot 
with  certainty  be  made  out  before  the  abdomen  is  opened. 

Rupture  of  an  ovarian  cyst  may  occur,  and  the  fluid,  if  it  escapes 
through  a  small  opening,  may  give  rise  to  no  special  symptoms;  but  if  it 
is  suddenly  evacuated  into  the  peritoneal  cavity  in  large  quantities,  col- 
lapse and  death  may  occur  at  once.  In  any  case,  the  escape  of  fluid  may 
give  rise  to  peritonitis ;  this  it  is  sure  to  do  if  the  contents  be  purulent. 
Twisting  of  the  pedicle  may  occur  from  rotation  of  the  tumor,  and  inflam- 
mation and  gangrene  of  the  growth  take  place  as  a  result. 

Treatment. — ^The  only  treatment  for  ovarian  cyst  is  removal  by 
laparotomy,  which,  at  the  present  day,  is  exceedingly  safe  if  the  operation 
be  properly  done.  Tapping  the  cyst,  so  often  employed  formerly,  is  not 
justifiable  as  a  general  course  of  treatment.  It  may  be  employed  to 
prolong  life,  when  removal  of  the  tumor  is  impossible;  or  it  may  be 
done  in  order  to  make  the  patient  comfortable  until  the  operation,  then 
unadvisable,  can  be  done.  For  example,  the  existence  of  an  acute  dis- 
ease may  render  immediate  ovariotomy  impossible.  Then  temporary 
relief  from  tapping  may  be  justifiable.  There  is  no  advantage  in  it  in 
order  to  make  an  examination  of  the  fluid  as  a  means  of  diagnosis,  since 
such  examination  is  fallacious.  Since  the  only  proper  treatment  cannot 
be  undertaken  without  opening  the  abdomen,  exploratory  incision,  fol- 
lowed by  immediate  removal  of  the  ovarian  cyst,  if  one  is  found,  is  the 
correct  surgical  procedure. 

Peritonitis,  due  to  rupture  of  a  cyst,  or  to  the  occurrence  of  suppura- 


DISEASES    AND    INJURIES    OF    THE    UTERUS. 


611 


tion  within  the  cyst,  indicates  immediate  operation.     Ovarian  cysts  have 
been  successfully  x'emoved  while  the  patient  was  pregnant. 

The  incision  for  removal  of  an  ovarian  cyst  should  be  about  three 
inches  long  in  the  middle  line  and  midway  between  the  navel  and  the 
pubes.  It  is  wise  to  go  no  nearer  to  the  pubes  than  two  inches,  to  make 
sure  that  the  bladder  be  not  injured.  The  incision  can  always  be  enlarged 
upward  with  safety  at  any  stage  of  the  operation.  If  the  surgeon  carries 
the  abdominal  incision  above  the  navel  it  is  best  to  carry  it  around  the 
outside  of  the  navel  on  one  side  rather  than  to  go  directly  through 
it.    All  hemorrhage  of  the  abdominal  wound  should  be  stopped  before  the 

Fig.  384. 


Tait's  ovariotomy  trocar. 


Fig.  385. 


peritoneum  is  opened.     The  cyst  is  then  tapped  with  a  trocar  before  the 
adhesions,  if  there  be  any,  are  broken  down,  and  the  contents  of  the  cyst 
allowed  to  flow  through  the  trocar.    The  wall  of  the  sac  should  be  drawn 
out  of  the  wound  to  prevent  extravasation  of  the  cystic 
fluid  into  the  peritoneal  cavity. 

The  adhesions  are  then  gradually  torn  through  with 
the  fingers,  or,  if  very  firm,  are  divided  with  a  pair  of 
scissors,  perhaps  after  previous  ligation.  Every  precau- 
tion to  prevent  hemorrhage  is  taken.  The  wound  made 
by  the  trocar  in  the  sac  should  be  closed  with  a  T-shaped 
hemostatic  forceps,  to  prevent  the  escape  of  cystic  fluid 
into  the  peritoneal  cavity. 

Injury  to  the  bowels  must  be  carefully  avoided  by 
detaching  the  adhesions  from  the  intestinal  wall  with 
caution.  Vascular  adhesions  must  be  ligated  in  a  way 
similar  to  that  adopted  for  tying  a  pedicle.  The  pedicle 
of  the  growth  is  found  after  the  sac  has  been  separated 
from  its  adhesions  and  drawn  through  the  wound,  and 
must  be  ligated  before  the  sac  is  cut  away.  This  is  best 
done  by  transfixing  the  pedicle  with  a  blunt  needle 
and  thereby  carrying  a  double  silk  ligature  through  it, 
or  by  thrusting  a  pair  of  closed  hemostatic  forceps 
through  the  pedicle,  by  which  the  ligature  is  seized 
in  the  middle  and  drawn  backward  through  the  opening 
made  by  the  forceps.  An  aneurism  needle  does  very  Thornton's  T-shaped 
well  for  this  purpose.     The  loop  of  the  suture  is  then  forceps, 

cut,  leaving  two  portions  of  silk  lodged  in  the  pedicle. 
After  a  twist  around  each  other  has  been  given  to  the  threads  at  the 
point  where  they  perforate  the  stump,  each  half  of  the  stump  is  tied  sepa- 


612  DISEASES    CF    THE    ABDOMEN     AND    PELVIS. 

rately.  One  of  tlie  ligatures  is  then  carried  around  the  whole  pedicle, 
making  the  ligation  more  secure,  and  the  ends,  by  means  of  needles 
threaded  upon  them,  may  be  carried  through  the  base  of  the  pedicle  on 
the  side  away  from  the  tumor,  and  tied  in  such  a  way  as  to  anchor  the 
whole  ligature.  This  prevents  the  possibility  of  its  slipping  from  the 
stump  when  the  tumor  is  removed. 

Various  forms  of  interlocking  ligatures  have  been  devised  for  use  upon 
the  pedicle.  One  of  the  best  is  the  Staffordshire  knot.  It  is  made  by 
carrying  a  double  ligature  through  the  middle  of  the  pedicle,  bringing  the 
loop,  which  is  on  one  side  of  the  pedicle,  over  the  tumor,  so  as  to  be  on 
the  same  side  as  the  two  free  ends,  and  then  passing  one  end  through  the 
loop.  One  end  is  thus  placed  over,  the  other  under,  the  loop.  The  two 
ends  are  then  pulled,  until  the  loop  is  tightened,  and  then  tied  with  a  flat 
knot.  The  cyst  is  then  cut  oft' outside  the  ligature,  and  the  ligated  stump 
dropped  into  the  belly.  The  toilet  of  the  peritoneum  nmst  be  carefully 
performed.  Drainage  should  be  instituted,  if  there  is  necessity  for  it  by 
rejison  of  pus  escaping  from  the  sac  into  the  cavity,  or  because  of  oozing 
of  blood  from  many  small  points  which  cannot  be  ligated. 

Solid  tumors  of  the  ovary  should  be  removed  by  laparotomy  and 
e.\cision.  The  handled  screw  of  Tait  may  be  inserted  into  the  mass  in 
order  to  render  its  manipulation  convenient. 


Diseases  of  the  F.vlloi'ian  Tubes. 

Tubal  disease  may  arise  as  a  consequence  of  uterine  and  pelvic  inflam- 
mations and  of  gonorrhoea.  Inflammation  of  the  tubes  is  called  salpin- 
gitis. Suppuratic^n  within  the  tubes  is  usually,  it  is  believed,  a  sequence 
of  gonorrhoea,  and  is  called  pyosalpinx.  Injury  of  the  Fallopian  tube, 
or  obstruction  to  the  escape  of  menstrual  fluid  from  the  vagina  or  uterus 
may  give  rise  to  distention  of  the  tube  by  blood  (htemato-salpinx).  A 
collection  of  serum  in  the  tube  causes  the  condition  called  hydro- 
salpinx. 

Tubal  disease  is  of  importance  to  the  surgeon  because  it  is  often  the 
cause  of  pelvic  and  abdominal  suppuration.  Purulent  peritonitis  is  often 
on  examination  found  to  be  due  to  rupture  of  the  Fallopian  tube,  which 
has  been  the  seat  of  suppurative  inflammation. 

The  symptoms  of  tubal  disease  are  pain,  especially  severe  upon  exertion 
or  coition,  tenderness  in  the  ovarian  region,  painful  and  irregular  men- 
struation and  various  distressing  symptoms  referred  to  the  pelvis  and 
uterus.  Symptoms  formerly  attributed  to  pelvic  cellulitis  were  probably 
in  the  majority  of  cases  indicative  of  tubal  disease.  Pelvic  cellulitis 
without  disease  of  the  uterine  appendages  is  now  believed  to  be  rare.  In 
disease  of  the  tubes  vaginal  examination  will  probably  reveal  the  pres- 
ence of  a  fluctuating  oblong  tumor  through  the  roof  of  the  vagina.  Such 
a  tumor  may  exist  upon  one  or  both  sides,  and  may  be  movable  or 
adherent.  The  elongated  shape  of  a  distended  tube  differs  from  that  of 
a  small  ovarian  cyst.  Pyosalpinx  sometimes  gives  rise  to  rigors  and 
febrile  conditions. 

The  treatment  of  diseased  tubes  is  largely  operative.  Hsemato-salpinx 
may,  perhaps,  be  excepted  from  the  rule  that  diseased  tubes  should  be 
removed  by  abdominal  section.  When  the  tube  contains  pus  there  is 
great  danger  of  spontaneous  or  accidental  rupture,  and  of  thus  creating 


HERNIA.  613 

purulent  peritonitis.  Hence  removal  is  demanded.  The  excision  of  tubes 
distended  with  serum  is  usually  judicious  treatment. 

The  operation  of  salpingectomy,  or  removal  of  the  tubes,  is  a  simple 
one,  and  consists  in  making  a  two-inch  incision  in  the  middle  line  of  the 
abdomen,  through  which  one  or  two  fingers  are  introduced.  The  adhe- 
sions, which  are  often  present,  are  carefully  torn  and  the  diseased  Fallopian 
tube  drawn  through  the  abdominal  incision.  The  ovary  should  be  brought 
out  along  with  the  tube  and  afterward  the  pedicle  secured  and  tied  with 
silk.  Great  care  must  be  exercised  in  operating  for  pyosalpinx  to  avoid 
rupture  and  escape  of  pus  into  abdomen  or  pelvis.  If  this  accident  hap- 
pens, as  it  may,  because  of  the  firmness  of  the  adhesions,  the  abdominal 
and  pelvic  cavities  must  be  well  irrigated,  and  subsequently  drained  by 
a  glass  or  rubber  tube  being  left  in  the  wound.  An  interlocking  ligature 
about  the  bi^oad  ligament  which  forms  the  stump  is  probably  the  safest. 

Oophorectomy,  or  removal  of  the  ovaries  when  not  the  seat  of  cystic 
disease  or  other  gross  lesion,  has  been  employed  in  the  treatment  of 
ovarian  neuralgia,  and  of  insanity,  epilepsy,  and  menorrhagia  accompany- 
ing fibro-myomatous  tumors. 

The  term  ovariotomy  is  usually  employed  to  indicate  removal  of  ovaries 
which  are  the  seat  of  cystic  or  solid  tumors.  It  will  be  seen,  however, 
that  oophorectomy,  which  etymologically  means  removal  of  the  ovaries, 
has  the  same  signification,  though  the  terms  are  usually  used  with  a  dis- 
tinction. Normal  ovariotomy  is  sometimes  employed  instead  of  oophorec- 
tomy. The  student  should  observe  that  the  latter  word  is  not  pronounced 
as  though  its  first  syllable  was  "  ou." 


Hernia. 

Definition. — Hernia,  or  rupture,  is  a  protrusion  of  any  portion  of  the 
abdominal  or  pelvic  contents  through  an  abnormal  opening  in  the  wall 
of  these  cavities,  not  a  recent  penetrating  wound.  The  tumor  is  usually 
covered  with  integument.  Such  is  not  the  case,  however,  in  hernia  through 
the  diaphragm,  nor  in  hernia  into  the  vagina  or  rectum. 

The  term  "hernia"  is  sometimes  applied  to  a  protrusion  of  other  struc- 
tures through  an  opening,  such  as  hernia  of  the  brain,  which  is  a  protru- 
sion of  cerebral  and  inflammatory  tissue  through  an  opening  in  the  skull, 
and  hernia  of  the  iris,  which  is  a  protrusion  of  the  iris  through  an  opening 
in  the  cornea. 

When  the  word  hernia  is  used  alone  it  refers  to  a  protrusion  of  the 
abdominal  and  pelvic  contents. 

Causes. — Hernia  is  apt  to  occur  where  the  wall  of  the  abdomen  or 
pelvis  is  weakened  by  the  passage  of  some  normal  structure,  such  as  the 
spermatic  cord,  the  round  ligament,  the  femoral  vessels,  or  by  a  cicatrix 
left  after  a  wound.  A  protrusion  through  a  recent  wound  is  not  called  a 
hernia,  but  a  protrusion  occurring  at  the  cicatrix  of  an  old  wound  is  a 
hernia. 

The  predisposing  causes  of  hernia  are  a  long  mesentery,  a  patent  funic- 
ular portion  of  the  vaginal  tunic  or  canal  of  Nuck,  congenital  defects 
in  the  wall  of  the  belly,  relaxed  muscles  from  pregnancy  or  emaciation, 
and  cicatrices. 

The  exciting  causes  are  muscular  exertion,  such  as  occurs  in  lifting 
heavy  weights,  straining  at  stool,  and  in  the  repeated  compression  of  the 
viscera  which  occurs  in  stricture  of  the  urethra,  phimosis,  stone  in  the 


614  DISEASES    OF    THE    ABDOMEN    AND    PELVIS. 

bladder,  and  chronic  cough.  These  conditions  <jive  rise  to  hernia  because 
tlie  muscuhir  contraction  involved  causes  a  diminution  of  the  cubical 
space  in  the  abdomen  and  jjclvis  and  tends  to  thrust  the  contents  of  these 
cavities  through  any  weak  portion  of  the  wall. 

Pathology. — The  ordinary  seats  of  hernia  are  the  inguinal  canal,  the 
femoral  canal,  the  umbilicus,  and  cicatrices  left  after  laj)arotomy  or 
accidental  penetrating  wounds  of  the  abdomen.  Hernia  at  the  obturator 
foramen,  at  the  great  sciatic  foramen,  or  through  the  diaphragm  into  the 
chest  is  rare.  A  diaphragmatic  hernia  may  occur  through  any  of  the 
normal  openings  in  that  muscle,  or  through  a  congenital  defect.  Hernia 
in  the  lumbar  region,  into  the  perineum,  or  into  the  space  between  the 
vagina  and  the  ramus  of  the  ischium  is  rare,  as  is  also  hernia  into  the 
rectum  and  vagina. 

A  hernial  tumor  usually  pushes  before  it  the  parietal  peritoneum, 
which  is  stretched  or  undergoes  interstitial  growth  by  force  of  the  descend- 
ing tumor,  and  forms  a  sac.  The  contents  of  the  sac  are  usually  intestine 
or  omentum,  but  almost  any  of  the  abdominal  or  pelvic  organs  may  be 
contained  in  the  hernial  protrusion.  Outside  of  the  sac  are  found  the 
fascias  and  muscular  structures  pertaining  to  the  region  in  which  the 
hernia  occurs. 

When  hernia  occurs  into  the  vaginal  tunic  of  the  testicle  because  the 
funicular  portion  in  the  inguinal  canal  has  not  become  obliterated,  the  con- 
dition is  called  a  congenital  hernia.  Here  there  is  no  true  hernial  sac  or 
protrusion  of  the  parietal  peritoneum,  since  the  canal  of  peritoneum  already 
existed  as  an  unclosed  foetal  structure. 

The  sac  of  a  hernia  has  a  body,  a  neck,  and  a  mouth  or  orifice,  through 
which  the  hernia  enters  the  sac.  The  sac  is  usually  pear-shaped  or  glob- 
ular, but  may  assume  almost  any  form.  It  may  be  divided  by  partitions 
into  separate  chambers,  and  in  one  or  more  of  these  chambers  there  may 
be  serous  fluid.  The  sac  walls  of  old  hernias  are  often  very  much  thick- 
ened ;  sometimes  they  are  irregularly  thinned  in  places.  The  neck  of  the 
sac  in  a  recent  hernia  is  more  or  less  folded  or  plaited,  but  in  old  cases  it 
usually  has  become  smooth,  indurated,  and  thickened  by  inflammatory 
deposits. 

When  the  contents  of  a  hernial  sac  consist  entirely  of  intestine  the 
hernia  is  called  an  enterocele.  A  hernia  consisting  of  omentum  is  au 
epiplocele ;  while  one  in  which  the  contents  are  both  intestine  and  omen- 
tum is  known  as  an  entero-epiplocele. 

The  ovaries  and  bladder  and  portions  of  the  solid  viscera  are  found  in 
some  large  hernias,  but  usually  it  is  the  small  intestine  with  or  without  a 
portion  of  the  omentum  which  is  found  in  the  hernial  sac.  In  rare  cases 
only  a  portion  of  the  calibre  of  the  knuckle  of  intestine  enters  the  her- 
nial sac,  which  in  this  case  of  course  is  small. 

An  untreated  hernia  may  become  exceedingly  large,  until  several  feet 
of  gut  lie  outside  of  the  abdominal  cavity.  The  intestine,  the  mesentery, 
and  the  omentum  of  au  old  hernia  usually  become  hypertrophied,  and 
more  or  less  adherent  to  each  other  and  to  the  sac  wall.  A  limited 
amount  of  serum  is  often  found  in  the  sac,  and  occasionally  rice-like 
bodies  composed  of  inflammatory  lymph  are  present.  If  a  hernia  has  been 
kept  within  the  abdomen  for  a  long  while  by  a  truss,  the  neck  of  the  sac 
may  become  obliterated  and  the  sac  remain  as  a  cyst  filled  with  serous 
fluid. 

When  the  protruded  viscera  can  be  pushed  back  into  the  cavity  of  the 
abdomen  the  hernia  is  said  to  be  "  reducible."     When  such  is  not  the 


HERNIA.  615 

case,  and  the  protruded  viscera  cannot  be  reduced  by  manipulation,  the 
hernia  is  called  "irreducible."  The  word  "incarcerated  "  is  sometimes 
employed  to  indicate  the  condition  of  irreducibility ;  unfortunately  it  is 
also  used  occasionally  as  synonymous  with  "obstructed"  hernia.  The 
latter  use  of  it  seems  to  me  improper. 

A  "  strangulated  "  hernia  is  one  in  which  the  protruded  viscera  are  so 
tightly  grasped  that  it  is  impossible  to  push  back  the  mass  into  the  ab- 
dominal or  pelvic  cavities,  and  in  which  circulation  of  the  part  protruded 
is  so  impeded  that  inflammation  or  gangrene  takes  place.  If  the  hernia 
which  is  strangulated  contains  intestine,  the  passage  of  the  feces  is  also 
prevented  by  the  compression  of  the  gut. 

In  an  "obstructed"  hernia  the  intestine  is  obstructed  with  a  mass  of 
undigested  food,  or  feces.  It  is  irreducible,  and  occurs  especially  in  old 
persons.  The  liability  of  such  hernias  to  become  strangulated  or  inflamed 
is  very  great. 

An  "  inflamed  "  hernia  is  one  in  which  the  sac  contents  are  in  a  condi- 
tion of  inflammation.  This  pathological  condition  is  most  common  in 
small  irreducible  hernias,  and  is  due  to  wearing  an  ill-fitting  truss,  or  to 
violent  exercise  or  injury.  An  inflamed  hernia  is  apt  to  become  stran- 
gulated. 

In  reducible  hernia  the  hernial  contents  often  return  into  the  belly 
spontaneously  when  the  patient  lies  upon  his  back.  The  sac,  in  recent 
cases,  sometimes  goes  back  at  the  same  time  that  the  intestine  and 
omentum  do.  In  most  cases,  however,  the  sac  remains  adherent  to  the 
surrounding  structures  after  its  contents  have  spontaneously,  or  by  manip- 
ulation, been  returned  to  their  normal  site. 

A  hernia  becomes  irreducible  because  of  changes  in  the  vicinity  of  the 
ring,  in  the  protruded  tissues  themselves,  or  in  the  sac.  The  ring  or  open- 
ing may  have  become  inflamed,  and  thereby  contracted ;  the  neck  of  the  sac 
may  have  become  elongated  and  its  walls  thickened ;  the  protruded  struc- 
tures may,  from  growth  or  inflammation,  have  increased  in  size  below  the 
neck  after  their  extrusion  ;  adhesions  may  have  occurred  between  the  con- 
tents of  the  sac  and  the  sac  wall,  or  between  various  portions  of  the  hernial 
mass;  and,  finally,  bands  of  inflammatory  tissue  developed  within  the  sac, 
or  the  fluid  contained  in  it  may  interfere  with  the  reducibility  of  the 
hernia. 

A  recent  hernia  may  be  strangulated  by  suddenly  being  forced  through 
a  small  opening  which  instantly  exerts  great  constriction.  An  old  hernia 
may  become  strangulated  by  a  sudden  protrusion  of  a  new  portion  of  the 
intestine  or  omentum  in  addition  to  the  previous  mass ;  by  swelling  from 
inflammation  of  the  omentum  or  of  the  mucous  membrane  of  the  intes- 
tine, or  by  increased  size  of  the  gut  from  obstruction  with  gas  or  feces. 
The  constriction  causing  strangulation  may  be  at  the  outside  of  the  sac  at 
the  hernial  ring,  in  the  neck  of  the  sac  itself,  or  within  the  sac.  In  the 
last  case  the  strangulation  may  be  caused  by  inflammatory  bands,  or  by 
openings  between  two  portions  of  the  hernia  within  which  another  portion 
may  have  become  constricted.  Strangulation  may  be  acute  or  chronic  in 
its  course,  according  to  the  mechanism  which  produces  it. 

The  compression  of  veins  by  the  strangulation  gives  rise  to  venous  con- 
gestion, followed  by  inflammation  and  gangrene.  The  paralysis  of  the 
muscular  coat,  wdiich  sometimes  occurs,  may  interfere  with  peristaltic 
action  and  cause  obstruction  to  the  passage  of  the  feces,  although  the 
lumen  of  the  intestines  is  not  entirely  closed  by  the  pressure.  Strangula- 
tion may  occur  also  in  Littre's  hernia,  although  the  entire  calibre  of  the 


616  DISEASES    OF    THE    ABDOMEX    AND    PELVIS. 

intestine  is  not  constricted  in  this  form  of  hernia.  It  is  easily  understood 
that  the  greater  the  swelling  the  greater  the  constriction,  and  that,  at  the 
same  time,  the  increase  of  constriction  thus  caused  tends  to  produce  a 
further  increase  of  swelling.  A  strangulated  knuckle  of  howel  usually  at 
first  becomes  red,  then  of  a  dark  color,  and  finally  black  or  gray.  This 
last  condition  is  often  accompanied  with  ecchymbtic  spots.  The  swollen, 
sticky,  and  oedematous  coats  of  the  intestine  exhale  a  fecal  odor,  and 
exude  a  dark  fluid.  Sloughing  and  perforation  of  the  intestinal  wall 
occurs  as  a  later  step,  and  is  follow^ed  by  fecal  extravasation  into  the  sac, 
which,  if  the  patient  lives  long  enough,  ends  in  fecal  abscess,  and  in  the 
formation  of  a  fistule  between  the  gut  and  the  external  surface.  Peri- 
tonitis occurs  quite  early  after  strangulation  has  taken  place.  The  intes- 
tine soon  becomes  glued  to  the  belly  wall  surrounding  the  hernial  ring, 
and,  therefore,  in  cases  of  fecal  abscess,  the  extravasated  feces  are  not 
apt  to  escape  into  the  general  peritoneal  cavity.  In  the  majority  of  cases, 
death  takes  place  from  exhaustion  and  peritonitis  before  fecal  abscess  and 
fistule  have  occurred. 

Symptoms. — A  feeling  of  weakness  is  often  experienced  by  the  patient 
before  the  hernial  protrusion  takes  place.  A  fulness  in  the  part  is  per- 
haps perceptible,  and  suggests  the  occurrence  of  hernia  because  it  is  at  the 
locality  where  hernia  is  likely  to  occur.  If  the  disease  is  gradual  in  its  de- 
velopment, a  small  tumor,  not  larger  than  a  finger-tip,  may  at  length  be 
noticed  at  the  seat  of  this  fulness,  and  is  accompanied  by  a  subjective  sensa- 
tion of  weakness.  When  the  patient  lies  down  the  tumor  spontaneously  dis- 
appears, because  the  protruded  bowel  or  omentum  slips  back  into  its  normal 
position.  In  other  cases,  sudden  and  painful  protrusion  occurs  at  one  of 
the  ordinary  seats  of  hernia  during  straining  at  stool  or  violent  exercise. 

The  hernial  tumor  is  usually  round  or  oval,  and  rather  smaller  at  its 
base,  which  represents  the  seat  of  the  neck  of  the  sac.  It  is  enlarged 
when  the  patient  stands  or  coughs,  Init  disa])pears  under  gentle  pressure 
or  when  he  lies  down.  Coughing  causes  an  impulse  in  the  tumor,  which 
is  very  perceptible  to  the  hand  when  grasping  it.  If  the  hernia  consists 
of  intestine  alone,  the  tumor  is  smooth,  elastic,  tympanitic  on  ])ercussion, 
and  slightly  gurgling  when  compressed.  The  impulse  on  coughing  is 
marked.  Humbling  from  intestinal  gases  is  present,  and  the  patient  has 
a  dragging  sensation  at  the  seat  of  the  tumor.  Reduction  is  accompanied 
by  a  distinct  gurgling,  due  to  the  escape  of  gases  and  liipiid  feces,  and 
by  a  sudden  peculiar  croaking  sound  as  the  gut  slips  back  into  the  belly. 

If  the  hernia  contains  only  omentum,  the  tumor  is  apt  to  be  irregular 
and  to  have  a  doughy  feeling;  it  shows  less  impulse  on  coughing,  and 
when  being  reduced  slips  back  gradually  without  any  gurgling  or  croak- 
ing sound. 

The  symptoms  of  irreducible  hernia  are  not  unlike  those  already  de- 
scribed, except  in  so  far  as  the.se  symptoms  pertain  to  the  possibility  of 
the  protrusion  being  pushed  back  into  the  abdomen.  Colicky  pains  are 
rather  characteristic  of  irreducible  hernia.  In  some  cases,  where  both 
intestine  and  omentum  are  contained  in  the  .sac,  the  gut  is  reducible,  while 
the  omentum  is  irreducible. 

Strangulated  hernia  gives  rise  to  very  characteristic  symptoms.  The 
tumor  becomes  j)ainful,  tender,  and  tense,  and  a  tympanitic  note  is  given 
if  intestine  is  contained  in  the  sac.  Impulse  on  coughing  is  lost.  Pain 
is  usually  referred  to  the  umbilical  region,  which  is  the  reason  that  stran- 
gulated hernia  has  been  so  often  mistaken  for  ordinary  colic.  If  the  con- 
striction is  not  relieved  the  skin  overlying  the  gut,  which  has  become 


HERNIA.  617 

gangrenous,  assumes  a  dark  hue  and  gives  rise  to  a  fecal  odor.  The  sen- 
sation of  pain  is  apt  to  cease  if  gangrene  occurs.  To  the  uninitiated  this 
appears  to  be  a  good  omen.  The  surgeon,  however,  knows  that  it  is  a 
sign  of  grave  pathological  change.  The  intestinal  obstruction  due  to 
strangulation  causes  obstinate  constipation  and  vomiting.  Constipation 
is  complete  except  that  the  lower  bowel  may  be  emptied  of  its  contents 
during  the  earlier  hours  of  the  disease.  In  Littre's  hernia  constipation 
is  not,  as  a  rule,  complete.  Vomiting  is  violent  and  gushing  without  much 
retching.  The  vomited  material  is  at  first  the  contents  of  the  stomach, 
then  bile  and  the  other  fluids  found  in  the  upper  part  of  the  small  intes- 
tine are  ejected.  Finally  the  ejection  of  a  brownish-yellow^  fluid  with 
the  odor  of  feces  indicates  that  the  contents  of  the  lower  portion  of  the 
small  intestine  are  being  thrown  up.  This  fluid  is  indeed  feces,  and  to 
such  vomiting  the  name  "  stercoraceous  vomiting  "  is  given.  There  is  no 
flatus  discharged  from  the  rectum,  but  the  contents  of  the  large  bowel 
may  be  evacuated  either  voluntarily  or  after  the  administration  of  an 
enema.  The  face  becomes  pinched  and  anxious ;  the  pulse  is  frequent 
and  weak  and  perhaps  irregular  ;  .the  tongue  is  furred  and  brown.  There 
is  profund  collapse,  and,  later,  exhaustion  and  death  take  place.  Recovery 
after  the  formation  of  a  fecal  abscess  and  fistula  due  to  gangrene  of  the 
gut  does  occur,  but  it  is  rare.  In  young  persons  and  in  recent  hernia 
strangulation  usually  gives  rise  to  acute  symptoms,  while,  occurring  in  the 
irreducible  hernia  of  old  people,  the  strangulation  symptoms  are  apt  to 
be  more  chronic  in  their  course. 

Treatment. — The  palliative  treatment  of  reducible  hernia  is  the 
application  of  a  compress  of  gauze,  or  other  material,  to  hold  the  intes- 
tine within  the  abdomen  until  a  properly  fitting  truss  can  be  obtained 
from  the  instrument-maker.  A  hernial  truss  consists  of  a  pad  held  in 
place  over  the  hernial  ring  by  a  spring  around  the  pelvis.  The  truss 
varies  in  shape  and  size  in  accordance  with  the  seat  and  character  of  the 
hernia,  and  should  be  made  to  fit  comfortably,  and  to  make  only  such 
pressure  over  the  hernial  opening  as  will  retain  the  structures  which  are 
liable  to  protrude.  If  the  patient  can  be  seen  by  the  instrument-maker 
a  properly  fitting  truss  is  generally  readily  obtained.  When,  however, 
the  patient  lives  at  a  distance  from  a  large  city  the  surgeon  should  send 
the  instrument-maker  the  girth  of  the  pelvis  midway  between  the  crest  of 
the  ilium  and  the  great  trochanter,  describe  the  kind  of  hernia,  tell  on 

Fig.  386. 


Truss  for  inguinal  hernia. 


which  side  it  exists,  give  the  sex  and  age  of  the  patient,  and  express  his 
opinion  as  to  the  relative  strength  of  the  spring  required.  The  truss 
should  be  adjusted  while  the  patient  is  recumbent  and  the  hernia  reduced. 
It  should  always  be  w^orn  when  in  the  erect  position,  and  should  never 


618 


DISEASES    OF    THE    ABDOME.V    AND    PELVIS. 


be  taken  oH"  until  he  is  recumbent.  Many  patients  can  go  without  their 
trusses  at  night  l)ecause  there  is  little  tendency  for  the  hernia  to  recur 
while  they  are  lying  down.  Others  require  to  wear  a  truss  at  night,  but 
then  it  is  not  necessary  for  the  spring  to  make  as  much  pressure  as  during 
the  daytime.  Hence  a  weaker  truss  may  be  used.  A  truss  at  night  is 
wise  when  the  patient  suffers  from  a  cough.  It  usually  takes  some 
time  for  the  patient  to  become  accustomed  to  wearing  the  support,  as 
is  the  case  with  those  wearing  an  artificial  limb  or  spectacles  for  the 
first  time.     The  annoyance,  however,  is  only  temporary. 

Fio.  3N7. 


Truss  for  femoral  hernia.     This  lorin  is  applied  across  the  pelvis  from  the  sound  side. 


Fin. 


Truss  for  umbilical  hernia. 

A  properly  fitting  truss  should  permit  the  patient  to  go  up  and  down 
stairs,  and  jump  off  a  chair,  for  example,  without  permitting  escape  of 
the  hernia. 

If  the  pad  of  the  truss  irritates  the  skin,  as  it  often  does,  the  cutaneous 
surface  may  be  sprinkled  with  lycopodium  powder  and  bathed  frequently 
with  whiskey  and  alum. 

The  radical  treatment  of  hernia  consists  in  reducing  the  protrusion, 
obliterating  the  sac,  and  closing  the  ring.  In  young  persons  with  small 
hernias,  wearing  a  truss  may  induce  sufficient  inflammation  of  the  peri- 
toneum forming  the  sac  to  cause  the  latter's  obliteration.  This  is  espe- 
cially true  of  congenital  hernia,  in  which  the  uuobliterated  portion  of  the 
vaginal  tunic  very  readily  becomes  adherent  from  the  irritation  caused  by 
pressure  of  the  truss. 

In  other  cases  the  radical  cure  is  only  possible  by  operative  inter- 
ference. The  radical  treatment  is  especially  employed  in  inguinal 
hernia.  An  incision  is  made  over  the  tumor,  the  sac  separated  from  the 
surrounding  tissues,  and  the  protruding  viscera  returned  to  the  abdomen. 
Various  means  are  employed  for  dealing  with  the  sac  so  emptied  and 
separated.  Some  operators  invaginate  it  into  the  inguinal  canal  and 
sew  the  columns  of  the  ring  and  sac  together,  thus  making  a  sort  of  plug 
in  the  inguinal  canal.  Other  surgeons  carry  a  ligature  around  the  neck 
of  the  sac,  tie  it  after  having  reduced  the  hernia,  and  then  cut  off  the 
sac  below  the  ligature  and  sew  the  columns  of  the  ring  together.  The 
sac,  on  the  other  hand,  may  be  folded  up  into  a  plug  or  twisted  into  a 


HERNIA.  619 

rope  and  thrust  into  the  canal,  where  it  is  stitched  to  the  columns  of  the 
ring.  In  these  operations  the  peritoneum  lining  the  inner  surface  of  the 
abdomen  around  the  internal  ring  should  be  separated  from  the  parietes 
for  a  short  distance  from  the  circular  margin  of  the  ring.  This  is  done 
in  order  to  insure  solid  closure  of  the  ring  by  preventing  the  formation 
of  a  concavity  at  its  former  site,  which  tends  to  allow  the  pressure  of  the 
intestines  to  start  the  formation  of  a  new  hernial  sac  and  to  stretch  the 
closed  plug.  In  most  of  these  operati^ons  the  stump  of  the  sac  or  the 
ring  made  by  the  old  sac  is  supposed  to  be  stitched  behind  the  ring,  thus 
making  a  sort  of  pad  within  the  abdomen  at  that  point. 

After  dealing  with  the  sac  according  to  any  one  of  the  methods 
described,  the  internal  ring  is  closed  by  means  of  silk  sutures  carried  in 
various  ways  through  the  abdominal  aponeuroses  and  margins  of  the 
opening.     Then  the  wound  is  closed. 

In  one  of  the  operations  for  the  radical  cure  of  hernia  the  external 
wound,  instead  of  being  closed,  is  plugged  with  antiseptic  gauze  because 
healing  by  granulation  is  thus  effected  and  a  more  solid  cicatrix  pre- 
sumably made.  This  offers  more  resistance  to  protrusion  of  the  intestinal 
contents  than  a  cicatrix  made  when  union  takes  place  by  first  intention. 
At  least  such  is  the  theory. 

Excision  of  the  sac  may  be  employed  for  the  cure  of  femoral  and 
umbilical  as  well  as  for  inguinal  hernia.  The  borders  of  the  ring  in  fem- 
oral hernia  cannot,  however,  readily  and  satisfactorily  be  sewed  together, 
because  the  margins  of  the  ring  are  too  rigid. 

Ventral  hernia  occurring  after  laparotomy  is  treated  by  a  bandage, 
pad,  or  truss ;  or  by  excision  of  the  sac  and  stitching  the  borders  of  the 
opening  together. 

Radical  operations  for  hernia,  although  comparatively  safe  when  done 
with  antiseptic  precautions,  are  attended  with  a  certain,  though  limited 
amount  of  risk,  and  in  the  majority  of  cases  do  not  effect  a  truly  radical 
cure.  A  return  of  the  hernia  is  quite  frequent,  though  the  recurrent 
hernia  may  be  smaller  and  more  manageable  by  a  truss  than  was  the 
original.  Radical  operation  is  justifiable  in  reducible  hernias  which  are 
very  large  and  in  those  which  a  truss  will  not  properly  control. 

Irreducible  hernias  frequently  give  great  discomfort  from  their  bulk  or 
from  the  dyspeptic  symptoms  produced  by  their  existence.  In  irreduci- 
ble hernias  the  operation  for  radical  cure  is  more  serious  than  in  reducible 
hernias,  because  the  sac  has  to  be  opened  in  order  to  effect  the  reduction 
of  the  hernia.  The  intestinal  adhesions  have  to  be  released  and  portions 
of  omentum  perhaps  excised  in  order  to  accomplish  a  return  of  the  pro- 
truded viscera.  The  congenital  forms  of  hernia  are  more  amenable  to 
permanent  cure  by  radical  operation  than  other  forms,  but  they  are  also 
more  amenable  to  cure  by  truss. 

Irreducible  hernias  often  become  so  large  that  they  are  a  burden  to 
the  patient ;  and  they  are  dangerous  because  they  are  liable  to  inflamma- 
tion, strangulation,  and  obstruction.  An  attempt  should  be  made  to 
protect  them  from  injury  and  to  prevent  their  increase  in  size  by  wearing 
a  suitable  bag-shaped  truss  or  supporter.  If  a  hernia  has  recently  become 
irreducible  it  is  proper  to  attempt  to  render  it  reducible.  This  may  be 
accomplished  by  rest  in  bed,  the  administration  of  saline  laxatives,  and 
the  application  of  ice  to  the  surface  of  the  tumor.  Such  measures  are  of 
no  avail  unless  resorted  to  shortly  after  the  advent  of  irreducibility. 


620  DISEASES    OF    THE    ABDOMEN    AND    PELVIS. 


Strangulated  Hernia. 

Wlien  a  hernia  becomes  strangulated  the  reduction  must  be  made  at 
once,  since  everv  hour  adds  to  the  danger  of  the  condition  and  increases 
the  inflammatory  changes  in  the  gut  or  omentum  which  is  subjected  to 
pressure.  Purgatives  to  relieve  the  constipation  are  useless  and  extremely 
harmful.  Prolonged  and  forcible' manipulation  of  the  tumor  in  the  hope 
of  reducing  the  protruded  mass  is  equally  unjustifiable. 

The  word  "  taxis"  is  employed  to  describe  the  series  of  mani])ulations 
used  in  reducing  a  strangulated  hernia. 

AVhen  strangulation  has  occurred  taxis  should  at  once  be  attempted, 
but  the  surgeon  must  remember  that  the  manipulations  must  be  gentle 
and  continued  for  but  a  few  minutes.  If  reduction  by  taxis  is  not  ac- 
complished in  this  manner,  the  use  of  enemas  to  empty  the  lower  bowel, 
and  of  ice  locally  to  the  tumor,  and  the  internal  administration  of  mod- 
erate doses  of  morphia  may  be  adopted.  Ether  has  been  recommended 
as  a  local  application  because  of  its  refrigerant  effect.  In  some  kinds  of 
hernia  this  line  of  treatment  will  cause  the  tumor  to  become  reducible, 
and  gentle  taxis  employed  at  the  expiration  of  three  or  four  hours  will 
effect  reduction  of  the  strangulated  gut.  A  hot  bath  is  sometimes  appa- 
rently efficacious,  though  in  strangulation  of  femoral  hernia  it  appears 
to  be  valueless.  If  these  measures  fail,  immediate  resort  to  operation  for 
the  relief  of  the  strangulation  is  proper. 

In  attempting  to  reduce  a  hernia  by  taxis  the  surgeon  seizes  the  tumor 
with  one  hand  and  slightly  lifts  it,  exerting  at  the  same  time  a  little  pres- 
sure upon  it  with  his  fingers.  The  pressure  on  the  constricted  knuckle 
causes,  if  the  calibre  be  not  entirely  closed  by  the  constriction,  the  expul- 
sion of  gas  and  feces,  and  thereby  reduces  the  bulk  of  the  hernia.  With 
the  fingers  of  the  other  hand  he  slightly  compresses  tlie  protrusion  at  the 
neck  of  the  tumor  to  prevent  the  contents  from  bulging  over  the  ring 
when  pressure  is  being  made  with  the  other  hand.  It  is  often  well  to 
draw  down  the  tumor  a  little  with  the  right  hand  in  order  to  pull  out  a 
little  more  intestine  and  thus  disengage  the  protruded  portion  from  the 
grasp  of  the  ring  through  which  it  has  escaped.  It  is  clear  that  the 
portion  of  the  hernia  which  has  escaped  from  the  abdomen  last  must  be 
the  first  to  be  pushed  back.  Hence  the  part  near  the  neck  must  be 
"  coaxed  "  into  the  belly  before  the  lower  part  can  be  reduced.  During 
these  manipulations  the  pelvis  should  be  slightly  raised.  In  femoral 
hernia  the  thigh  should  be  flexed  and  rotated  a  little  inward  in  order  to 
relax  the  fascia  lata  which  forms  the  external  femoral  or  saphenous  open- 
ing.    The  pressure  exerted  during  taxis  should  be  gentle  and  steady. 

The  site  of  the  hernia  causes  a  variation  of  the  direction  in  which  the 
pressure  should  be  exerted,  for  it  is  easily  understood  that  the  gut  must 
follow  the  same  route  in  reduction  as  it  took  in  protrusion,  though  in  the 
opposite  direction.  Hence  the  line  of  pressure  proper  in  an  inguinal  hernia 
is  not  suitable  for  the  reduction  of  an  umbilical  or  femoral  hernia.  In  the 
discussion  of  Special  Hernias  the  direction  in  which  taxis  should  be  era- 
ployed  in  each  variety  will  be  given. 

When  strangulation  is  relieved  and  the  hernia  slips  back  into  the  abdo- 
men, a  peculiar  croak  is  heard  if  there  be  gut  in  the  tumor.  If  the  re- 
duction is  not  readily  effected  by  such  gentle  taxis,  the  surgeon  must 
desist,  since  force  or  too  long  employment  of  taxis  may  cause  bruising  of 
the  intestine,  and  sometimes  actual  rupture.     Two   minutes  is  probably 


HERNIA.  621 

long  enough  to  continue  the  efforts  in  a  small,  tight  femoral  hernia,  and 
about  five  minutes  in  other  hernias,  whether  femoral,  inguinal,  or  um- 
bilical. 

Taxis  is  more  successful  in  relieving  strangulation  of  recent  hernias 
than  of  old  hernias.  It  is  also  more  effective  in  inguinal  than  in  femoral 
hernias.  Anaesthetics  should  always  be  resorted  to  after  the  first  efflorts 
at  taxis  have  been  ineffectual.  It  is  usually  best  to  gain  the  consent  of 
the  patient  to  operation  before  administering  the  anaesthetic  so  that  the 
surgeon  may  proceed  at  once  to  radical  measures  if  taxis  under  anaes- 
thesia proves  unavailing.  If  any  other  surgeon  has  previously  made 
protracted  efforts  to  relieve  the  strangulation  by  taxis,  or  the  hernial 
tumor  is  tender  and  inflamed,  it  is  unwise  to  make  repeated  efforts  at 
reduction.  When  fecal  vomiting  has  existed  for  some  time  and  hiccough 
has  occurred,  and  especially  so  in  femoral  hernia,  it  is  not  wise  to  make 
efforts  at  taxis.  The  danger  in  these  cases  lies  in  the  fact  that  injurious 
pressure  may  be  made  upon  an  already  inflamed  and  gangrenous  intes- 
tine, which  will  be  followed  by  rupture  of  the  gut  or  fatal  peritoneal  in- 
flammation. Operation  is  in  such  cases  to  be  undertaken  without  running 
the  risk  of  causing  damage  by  taxis. 

The  operation  for  relief  of  strangulation  of  a  hernia  is  called  herniotomy, 
or  kelotomy. 

Herniotomy  or  Kelotomy. 

Herniotomy  is  undertaken  for  the  purpose  of  liberating  the  constricted 
bowel  or  omentum,  so  that  the  protruded  structures  may  be  returned  to 
the  abdominal  cavity.  If  the  protruded  organs  are  gangrenous,  so  that 
their  return  would  be  followed  by  serious  consequences,  their  excision,  the 
establishment  of  an  artificial  anus,  or  the  resection  of  intestine,  with  or 
without  immediate  suturing,  is  accomplished. 

The  incision  in  herniotomy  is  made  in  the  long  axis  of  the  tumor,  and 
the  coverings  of  the  hernia  down  to  the  sac  are  carefully  divided  in 
the  same  direction,  or  are  torn  apart  by  means  of  the  fingers,  forceps,  or 
the  handle  of  a  scalpel.  By  this  procedure  the  hernial  sac  is  exposed. 
Care  must  be  taken  that  the  sac  is  identified,  because  if  it  is  opened  un- 
wittingly, the  intestinal  wall  may  be  mistaken  for  the  sac  and  incised. 

Characteristics  of  the  sac  are  its  tense,  smooth  appearance,  and  the 
longitudinal  direction  in  which  its  vessels  run.  The  bloodvessels  of  the 
intestines  run  around  the  gut  in  a  direction  transverse  to  its  long  axis. 
Often  the  sac  may  be  picked  up  from  the  contents  of  the  hernia  in  such 
a  way  that  the  bowel  may  be  felt  to  slip  away  from  between  the  fingers 
holding  the  sac.  In  some  instances  in  which  the  sac  is  distended  with 
fluid,  the  sac  wall  is  so  thin  that  the  coils  of  intestine  or  omentum  may 
be  distinctly  recognized  within.  The  sac  usually  does  not  feel  as  thick  as 
the  intestine,  when  pinched  between  the  fingers. 

Under  certain  circumstances,  it  is  wise  to  divide  the  stricture  without 
opening  the  sac,  because  opening  the  sac  is  to  expose  the  intestine  to  con- 
tact with  air,  and  to  invade  the  general  peritoneal  cavity,  which,  of  course, 
is  in  direct  connection  with  the  cavity  of  the  sac.  This  method  of  reliev- 
ing a  strangulated  hernia  is  called  the  lesser  operation  for  hernia,  or  the 
method  of  Petit.  In  it  the  neck  of  the  sac,  which  has  just  been  exposed 
by  the  incision,  is  thoroughly  separated  from  its  surroundings,  and  the 
surgeon's  finger-nail  carefully  insinuated  under  the  edge  of  the  constrict- 
ing band.     This  is  then  divided  with  a  blunt-pointed  bistoury,  or  hernia 


622  DISEASES    OF    THE    ABDOMEN    AXD    PELVIS. 

knife.  Soinetiine.s  the  finger's  tip  can  be  insinuated  under  the  band  which 
stranguhites.and  the  constriction  relieved  by  stretching  or  tearing  the  tense 
tissues.  It'  a  knife  is  used,  two  or  three  small  notches  are  better  than  one 
deep  one,  since  there  is  then  less  danger  of  wounding  the  surrounding 
structures.  Gentle  efi'brts  at  taxis  will  then  reduce  the  hernia,  after  which 
the  edges  of  the  hernial  ring  are  stitched  together,  and  an  ordinary  gauze 
dressing  applied. 

Herniotomy,  without  opening  the  sac,  should  not  be  performed  when 
there  is  danger  of  the  gut  being  in  bad  condition  because  of  the  length  of 
time  that  strangulation  has  existed,  nor  when  the  hernia  is  known  to  have 
been  previously  irreducible.  It  is  very  evident  that  in  cases  where  rup- 
ture of  the  gut  from  forcible  taxis  is  suspected,  that  it  is  necessary  to  open 
the  sac  in  order  that  the  exact  condition  of  affairs  may  be  siscertained  In 
other  cases  it  becomes  necessary  to  open  the  sac  because  attempts  to  relieve 
the  strangulation  without  laying  open  the  sac  have  been  abortive. 

When,  therefore,  it  becomes  necessary  to  open  the  sac,  either  because 
the  strangulation  cannot  be  relieved  otherwise,  or  because  the  suspected 
condition  of  the  hernia  makes  a  full  investigation  imperative,  the  sac  is 
picked  up  at  one  point  with  a  forceps,  and  its  wall  punctured  by  means  of 
a  knife  held  horizontally.  The  small  opening  thus  made  is  enlarged  until 
the  whole  interior  of  the  sac  is  exposed  to  examination.  It  is  often  possi- 
ble to  tear  through  the  thin  sac  with  the  finger-nail.  This  is  safer  than 
using  a  knife.  Ordinarily,  however,  there  is  not  much  danger  of  injury 
to  the  gut,  because  in  many  cases  there  is  fluid  to  fill  the  space  between 
the  intestine  and  the  sac  wall.  Occasionally,  however,  the  gut  lies  in  im- 
mediate contact  with  the  sac  wall ;  then  considerable  care  is  necessary  to 
avoid  injuring  it. 

If  the  fluid  within  the  sac  is  simply  yellow  serum,  the  condition  of  the 
contents  of  the  sac  may  be  considered  good.  The  escape  of  bloody  or 
turbid  fluid,  however,  and  especially  if  it  exhales  a  fecal  odor,  is  indicative 
of  inflammatory  and  gangrenous  intestine  or  omentum.  The  stricture  is 
next  sought  for  with  the  finger,  and  at  the  same  time  any  adhesions  be- 
tween the  intestine  and  omentum,  or  between  these  structures  and  the  sac, 
are  broken  down.  The  finger-nail  is  then  slipped  under  the  strangulating 
band,  and  the  blunt-pointed  bistoury  or  hernia  knife  carried  along  the 
pulp  of  the  finger  until  it  lies  beneath  the  constriction.  The  knife  should 
be  pushed  under  the  band  lying  flat  upon  the  finger.  After  it  has  been 
put  in  proper  position,  the  edge  is  turned  against  the  tight  band  and  used 
so  as  to  make  two  or  three  shallow  nicks,  which  are  better  than  a  single 
deep  one.     After  division  of  the  stricture,  taxis  is  undertaken. 

Fig.  389. 


Levis's  notched  hernia  director. 

If  sufficient  division  of  the  stricture  has  not  been  performed,  as  indi- 
cated by  the  impossibility  of  reduction,  the  strangulated  band  should  be 
divided  or  torn  a  little  more.  In  those  cases  in  which  the  strangulation 
is  too  tight  to  permit  the  entrance  of  the  tip  of  the  finger,  a  hernia 
director  should  be  carefully  inserted  under  the  tense  band.  One  of  the 
best  forms  is  the  Levis  notched  hernia  director,  which  catches  the  strangu- 


HERNIA.  623 

lating  band  in  a  notch  and  holds  aside  the  intestines,  so  that  their  injury 
with  the  knife  is  almost  impossible. 

If  the  intestine  is  found  to  be  gangrenous,  the  constricting  band  should 
be  notched,  and  nothing  more  done ;  since  breaking  up  the  adhesions  is 
to  permit  access  to  the  general  abdominal  cavity  of  the  fetid  fluid  con- 
tents of  the  hernial  sac.  After  the  constriction  has  thus  been  relieved  an 
incision  should  be  made  into  the  calibre  of  the  gangrenous  intestine,  to 
permit  the  escape  of  feces.  An  artificial  anus  or  fecal  fistula  Avill  then  be 
established  at  the  site  of  the  operation.  This  may  be  treated  by  operation 
some  weeks  later,  when  the  patient  has  recovered  from  the  immediate  re- 
sults of  the  strangulation. 

In  some  cases  of  omental  hernia,  a  small  knuckle  of  gut  is  wrapped  up 
or  covered  by  the  omentum.  This  should  be  sought  for  before  the  omental 
hernia  is  returned,  since  the  whole  mass  may  be  returned  with  the  hidden 
intestine  still  strangulated. 

In  many  cases  of  operation  for  strangulated  hernia  it  is  difficult  to  de- 
cide whether  the  intestine  is  in  condition  to  be  returned.  The  question  is 
easy  enough  of  determination  in  cases  where  actual  gangrene  has  occurred, 
and  in  instances  where  there  is  "not  a  great  deal  of  inflammation;  but 
there  are  many  border-line  cases  which  require  serious  consideration.  If 
the  fluid  in  the  sac  is  serous,  and  the  intestine,  though  congested,  still  has 
a  shiny  surface,  it  is  proper  to  return  it.  If  its  walls  are  ashy-gray  in 
color,  and  show  no  evidence  of  elasticity,  it  is  equally  clear  that  gangrene 
has  taken  place,  that  the  mass  should  not  be  returned,  and  that  an  artificial 
anus  should  be  established.  If  the  intestine  is  extensively  diseased,  resec- 
tion of  the  gangrenous  portion  should  be  performed.  In  such  an  event 
the  open  ends  of  the  bowel  should  be  stitched  to  the  external  wound,  in 
order  that  the  fecal  contents  may  escape  upon  the  surface  of  the  body. 
If  the  gut  is  purplish  in  color,  shows  ecchymotic  spots,  and  is  covered  with 
sticky  lymph,  it  is  not  always  clear  whether  it  should  be  returned.  If  a 
large  coil  presents  this  condition,  it  may  be  left  in  the  hernial  sac  after 
the  strangulation  has  been  relieved,  so  that  in  the  event  of  sloughing  the 
extravasated  feces  and  the  contaminating  fluids  from  the  diseased  struc- 
tures may  be  kept  outside  of  the  abdominal  cavity.  Where  a  very  small 
knuckle  jDresents  these  characteristics,  the  surgeon  may  sometimes,  with 
wisdom,  push  the  knuckle  just  inside  the  ring,  where  it  will  probably 
become  adherent  to  the  belly  w^all.  If  sloughing  then  occurs  and  gives 
rise  to  perforation,  the  feces  will  have  an  opportunity  to  escape  into  the 
sac,  which  has  been  left  open,  without  invading  the  general  peritoneal 
cavity. 

If  by  accident  the  intestine  has  become  opened  during  the  division  of 
the  coverings,  the  wound  should  be  brought  together  by  Lembert's  sutures, 
as  described  in  Wounds  of  the  Intestines.  Subsequently  it  should  be 
returned  to  the  abdomen  as  if  no  such  accident  had  occurred.  If  the 
protruded  omentum  is  small  in  amount,  and  not  gangrenous,  it  should  be 
returned.  If,  however,  a  large  omental  mass  is  present,  or  if  an  omental 
hernia  of  any  size  is  thickened  or  inflamed,  a  ligature  should  be  cast 
around  it  near  the  neck  of  the  sac,  the  part  outside  of  the  ligature 
cut  off",  and  the  stump  pushed  back  into  the  abdomen.  A  silk  ligature 
is  best  and  should  include  the  entire  mass  in  a  single  stump.  The  effort 
to  tie  individual  omental  vessels  is  injudicious. 

The  last  step  in  herniotomy  is  the  treatment  of  the  sac.  If  the  patient 
is  weak,  or  if  complications  arise  from  the  condition  of  the  gut,  or  from 
peritoneal  inflammation,  the  sac  should   be  let  alone  and  the  external 


624  DISEASES    OF    THE    ABDOMEN    AND    PELVIS. 

wound  closed  with  sutures  or  left  open  as  previously  described.  If,  how- 
ever, these  complications  do  not  exist,  the  sac  should  be  dissected  away 
from  the  surrounding  coverings,  its  neck  ligated,  and  the  body  of  the 
sac  excised.  This  procedure  is  an  attempt  to  produce  a  radical  cure 
of  the  hernia,  as  by  obliteration  of  the  sac  a  recurrence  of  the  protrusion 
mav  be  prevented.  In  inguinal  hernia  the  columns  of  the  ring  may 
then  be  sewed  together  with  silk.  In  femoral  hernia  such  drawing 
together  of  the  margins  of  the  ring  is  probably  impossible.  In  umbilical 
hernia  the  sac  should  be  cut  away  and  the  edges  of  the  ring  freshened 
and  drawn  together  with  sutures. 

The  after-treatment  of  cases  of  hernia  is  identical  with  that  of  other 
abdominal  operations.  Some  pressure,  however,  should  be  made  upon 
the  wound  by  the  dressing  in  order  to  prevent  recurrence  of  the  hernial 
protrusion. 

The  symptoms  of  strangulation  usually  disappear  immediately  after 
the  reduction  of  the  gut,  whether  it  has  been  accomplished  with  or  with- 
out operation. 

A  persistence  of  vomiting  due  to  the  amesthetic  may  seem  to  indicate 
that  the  hernia  has  not  been  relieved.  This  vomiting,  however,  soon 
stops;  it  has  not  the  gushing  character  of  vomiting  from  strangulation, 
and  is  more  apt  to  be  accompanied  with  retching.  Temporary  paralysis 
of  the  muscular  coat  of  the  gut  by  interfering  with  peristalsis  may  simu- 
late a  condition  of  strangulation,  while  the  presence  of  another  unsus- 
pected hernia  which  is  strangulated  may,  of  course,  give  rise  to  a  continu- 
ation of  the  dangerous  symptoms.  Sometimes  a  hernia  which  is  believed 
to  have  been  reduced  ha.s  simply  been  pushed  backward  in  mass  and  lies 
between  the  transversalis  fascia  and  peritoneum.  In  such  instances  the 
strangulation  persists,  although  the  tumor  has  disappeai'ed  from  the  origi- 
nal site,  and  of  course  the  symptoms  continue.  Gangrene  of  the  gut 
occurring  after  reduction  may  cause  perforation  and  peritonitis.  In  rare 
instances  the  intestine  may  become  strangulated  within  the  abdomen  as  a 
result  of  inflammation  in  the  neighborhood  of  the  hernia.  Acute  enter- 
itis and  peritonitis,  moreover,  may  give  rise  to  alarming  symptoms.  In 
all  such  cases,  if  within  a  reasonable  time,  the  cause  of  the  complication 
is  not  evident,  laparotomy  in  the  median  line  should  be  performed. 

It  is  impossible  to  insist  too  strongly  upon  the  necessity  for  early  inter- 
ference in  cases  of  strangulated  hernia.  Nearly  all  cases  will  promptly 
recover  if  strangulation  is  quickly  relieved,  while  nearly  all  will  terminate 
fatally  if  this  is  not  effected.  It  is  the  continuation  of  efforts  at  taxis 
and  the  postponement  of  operation  that  causes  the  fatality  in  patients  the 
subjects  of  this  dangerous  surgical  disorder. 


Special  Hernias. 

The  most  common  sites  of  hernia  are  the  inguinal  canal,  the  femoral 
canal,  and  the  umbilicus;  hence,  inguinal,  femoral,  and  umbilical  hernias 
must  receive  special  consideration. 


Inguinal  Hernia. 

Anatomy. — In  inguinal  hernia  the  intestine  or  omentum  is  protruded 
from  the  abdomen  through  the  inguinal  or  spermatic  canal.     In  some 


SPECIAL    HERNIAS. 


625 


cases  the  hernia  traverses  the  entire  length  of  the  canal,  whereas  in  other 
cases  it  comes  through  the  abdominal  wall  directly  behind  the  external 
opening ;  which  is  called,  anatomically,  the  external  inguinal  or  spermatic 
ring.  In  the  former  case  the  hernia  is  called  an  oblique  inguinal  hernia,  in 
the  latter  case  a  direct  inguinal  hernia.  In  the  first  variety  the  neck  of 
the  hernial  protrusion  lies  external  to  the  deep  epigastric  artery,  but  in  the 
second  variety  it  is  internal  to  that  vessel.  In  oblique  hernia,  then,  the 
intestine  leaves  the  abdominal  cavity  at  the  internal  inguinal,  or  sper- 
matic, or  abdominal  ring,  follows  the  canal  through  the  abdominal  wall 
and  escapes  at  its  lower  opening,  called  the  external  inguinal,  or  spermatic, 
or  abdominal,  ring.  Here  it  appears  as  a  tumor  lying  outside  of  the 
aponeurosis  of  the  external  oblique  muscle,  just  above  the  body  of  the 
pubic  bone.  If  the  protrusion  is  not  large  enough  to  follow  the  course 
of  the  entire  canal  and  make  its  exit  at  the  external  ring,  the  hernia 
is  called  "  incomplete,"  because  the  viscera  have  not  completely  followed 
the  canal,  but  lie  within  it.  If  the  hernia  escapes  from  the  external 
ring  it  is  a  "  complete  "  one.  As  the  complete  hernia  increases  in  size 
the  intestine  descends  into  the  scrotum  or  vulva,  and  it  is  then  denomi- 
nated a  "  scrota]  "  or  "  labial "  hernia.  An  incomplete  hernia  is  often 
termed  a  bubonocele. 

The  coverings  of  a  complete  oblique  inguinal  hernia  are  skin,  superficial 
fascia,  inter-columnar  fascia,  cremasteric  fascia,  funnel-shaped  process  of 
the  transversalis  fascia  (infundibuliform  fascia),  subperitoneal  fat,  and 
peritoneum  (sac).  In  the  female  there  is  no  cremaster  fascia,  and  hence 
this  covering  is  wanting.  In  incomplete  oblique  inguinal  hernia,  instead 
of  the  inter-columnar  fascia,  there  is  a  covering  formed  by  the  aponeu- 
rosis of  the  external  oblique  muscle,  and  instead  of  the  cremasteric  fascia 
the  lower  fibres  of  the  internal  oblique  and  transversalis  muscles  make  a 
covering.  In  this  instance  there  is  no  difference  between  the  male  and 
the  female.  The  pupil  must  remember  that  the  words  "abdominal," 
"inguinal,"  and  "spermatic"  are  indiscriminately  used  to  describe  the 
canal  and  its  inner  and  outer  orifices.  The  different  adjectives  mean  the 
same  thing. 

The  stricture  in  strangulated  oblique  inguinal  hernia  occurs  at  either 
the  internal  or  external  ring,  or  in  the  canal. 


Fig.  390. 


Fig.  391. 


Fig.  392. 


Diagram  of  "  congenital 
hernia."    (Bryant.) 


Diagram  of  "  acquired 
hernia."     (Bbyant.) 


Diagram  of  "  acquired  con- 
genital hernia,"  or  the  "  en- 
cysted hernia  of  Cooper." 
(Betant.) 

There  are  several  varieties  of  oblique  inguinal  hernia.  In  the  acquired 
form  the  peritoneal  sac  is  pushed  down  through  the  inguinal  canal  and 
into  the  scrotum,  so  that  the  hernia  usually  lies  above,  or  in  front  of  and 
above,  the  testicle  or  cord. 

40 


626 


DISEASES    OF    THE    ABDOMEN    AND    PELVIS. 


In  congenital  inguinal  liernia  the  intestine  descends  into  the  scrotum 
along  the  unohliterated  funicular  process  of  the  peritoneum  which 
makes  the  foetal  canal  between  the  vaginal  tunic  of  the  testicle  and  the 
abdomen.  In  these  instances  the  protruded  gut  lies  within  the  vaginal 
tunic  and  comes  in  direct  contact  with  the  testicle.  There  is  no  true 
hernial  sac. 

In  another  form  the  hernial  sac  may  be  pushed  down  behind  the 
unohliterated  funicular  process,  and  give  rise  to  what  has  been  termed 
infantile  inguinal  hernia.  Varieties  of  inguinal  hernia  occur  in  which 
the  relations  of  the  sac  and  the  funicular  process  vary  from  the  most  fre- 
quent varieties  just  given. 

Direct  inguinal  hernia  is  a  protrusion  through  the  abdominal  wall  be- 
hind the  external  inguinal  ring.  In  this  variety  the  gut  does  not  enter 
the  canal  at  all,  but  after  piercing  the  w'all  escapes  through  the  external 
ring.  Sometimes,  however,  it  bursts  through  the  belly  wall  a  little  out- 
side of  the  external  ring,  and  then  does  enter  the  lower  part  of  the  canal 
before  emerging  at  the  ring.  The  neck  of  the  sac  in  both  varieties  of 
direct  hernia  is  internal  to  the  deep  epigastric  artery. 


Fig.  39.3. 


Fig.  394. 


Oblique  inguinal  hernia.     (Bryant.) 


Direct  inguinal  hernia.     (BkyAnt.) 


The  protruding  intestine  in  direct  hernia  may  push  the  conjoined  tendon 
in  front  of  it,  may  go  through  an  opening  in  the  tendon,  or  may  pass 
under  its  lower  border.  The  coverings  of  direct  inguinal  hernia  are  skin, 
superficial  fascia,  inter-columnar  fascia,  conjoined  tendon,  transvei-salis 
fascia,  subperitoneal  fat,  and  peritoneum  (sac).  It  is  evident  that  a 
covering  from  the  conjoined  tendon  will  not  be  present  if  the  hernia,  in- 
stead of  stretching  and  pushing  forward  this  tendon,  perforates  it  or  goes 
under  its  lower  border.  The  strangulation  of  a  direct  inguinal  hernia 
occurs  at  the  external  ring,  or  at  the  opening  in  the  conjoined  tendon. 

DiAGNCSis. — The  differential  diagnosis  between  oblique  and  direct 
hernia  is  often  difficult,  because  when  oblique  hernia  attains  considerable 
size,  or  has  existed  for  a  long  time,  the  internal  ring  is  by  the  weight  of 
the  tumor  dragged  down  until  it  is  directly  behind  the  external  open- 
ing. The  neck  of  the  sac,  therefore,  lies  immediately  over  the  body  of 
the  pubes,  and  seems  to  be  at  the  external  inguinal  ring.  It  is  under- 
stood, of  course,  that  a  direct  hernia  may  de.scend  into  the  scrotum  or 
labium  exactly  as  does  an  oblique  hernia. 


SPECIAL    HEENIAS.  627 

Inguinal  hernias  present  the  general  signs  and  symptoms  of  all  hernial 
tumors.  The  neck  of  the  sac  in  old  oblique  hernias,  and  in  recent  direct 
ones,  as  has  just  been  stated,  is  over  the  body  of  the  pubes  and  internal  to 
the  spine  of  the  pubes.  In  recent  oblique  hernias  the  inguinal  canal  is 
filled  up  with  a  protrusion  which  can  be  seen  and  felt,  occupying  an 
oblique  position  above  Poupart's  ligament.  The  tumor  is  reducible  at 
first,  if  subjected  to  moderate  pressure  applied  upward  and  outward. 

An  incomplete  oblique  hernia  might  be  mistaken  for  a  femoral  hernia 
which  has  curled  up  over  Poupart's  ligament,  but  is  differentiated  by  the 
fact  that  a  femoral  hernia  has  its  neck  below  Poupart's  ligament.  More- 
over, a  femoral  hernia  to  turn  up  so  as  to  overlie  Poupart's  ligament  must 
be  large,  and  is  reduced  by  pressure  applied  at  first  downward  and  back- 
ward, and  then  a  little  upward.  The  inguinal  canal  in  femoral  hernia 
is  unoccupied  by  a  mass,  while  in  oblique  inguinal  hernia,  even  when  in- 
complete, the  mass  seems  to  fill  up  or  to  occupy  at  least  part  of  the 
canal. 

Chronically  enlarged  lymphatic  glands  may  resemble  inguinal  hernia, 
but  here  the  tumor  is  apt  to  show  the  characteristic  signs  of  enlarged 
or  inflamed  glands,  and  the  inguinal  canal  is  unoccupied  by  any  swelling. 
The  characteristic  imjaulse  of  hernia  is  also  absent. 

An  encysted  hydrocele  of  the  spermatic  cord  occupies  a  position  similar 
to  inguinal  hernia.  It  is,  however,  tense,  oval,  and  well-defined  in  out- 
line, and  without  impulse.  A  cyst  of  the  canal  of  Nuck  in  the  female 
presents  similar  characteristics  An  encysted  hydrocele  of  the  spermatic 
cord  can  usually  be  pushed  up  into  the  belly. 

An  undescended  testicle  may  be  discriminated  from  an  inguinal  hernia 
by  absence  of  impulse  on  coughing,  and  by  the  facts  that  the  tumor  is 
not  reducible,  that  pressure  produces  the  peculiar  sickening  testicular 
pain,  and  that  the  testicle  on  the  corresponding  side  is  absent  from  the 
scrotum.  An  inflamed,  undescended  testicle  may  give  rise  to  vomiting 
which  will  suggest  strangulated  hernia.  The  vomiting,  however,  is  not 
gushing,  as  is  that  which  occurs  as  a  symptom  of  strangulated  hernia.  In 
doubtful  cases  an  exploratory  incision  is  justiflable. 

A  scrotal  hernia  may  be  confounded  with  hydrocele,  orchitis,  solid 
tumor  of  the  testicle,  and  varicocele.  Hydrocele  of  the  vaginal  tunic  is 
often  translucent,  and  is  a  tense,  semifluctuating  tumor  without  impulse. 
Its  rounded  upper  margin  is  generally  very  distinctly  felt  when  the  sur- 
geon's fingers  are  placed  upon  the  upper  part  of  the  cord  and  the  tumor 
is  pushed  up  against  these  fingers  by  pressure  exerted  with  the  other 
hand.  This  well-defined  upper  limit  is  very  different  from  the  gradual 
extinction  of  the  upper  portion  of  a  hernia  as  it  blends  with  or  is  lost  in 
the  belly  wall. 

It  must  not  be  forgotten,  however,  that  in  hydrocele  of  infants  the 
fluid  can  sometimes  be  pushed  back  into  the  abdomen  so  as  to  simulate 
hernia.  There  is,  fortunately,  no  such  croaking  sound  accompanying  the 
disappearance  of  the  tumor  as  is  frequently  heard  in  reducible  hernia. 
Unfortunately  for  diagnostic  purposes  the  hernia  of  children  is  sometimes 
translucent,  and  thus  resembles  hydrocele. 

In  orchitis  the  tumor  is  heavy,  showing  signs  of  inflammation,  and  is 
more  or  less  ovoidal  and  hard.  The  swelling  does  not  extend  up  into 
the  inguinal  canal. 

Varicocele  disappears  when  the  patient  lies  down,  is  increased  by  pres- 
sure made  upon  the  external  inguinal  ring,  gives   the  sensation  of  a 


628 


DISEASES    OF    THE    ABDOMEN    AND    PELVIS. 


Fig.  so.'). 


bag  of  worms  under  the  skin,  and  coughing  conveys  to  the  tiiiger  a  thrill 
rather  than  an  impulse.     Reducible  ln.'rnia  is,  after  reduction,  prevented 

from  recurring  by  pressure  at  the  ex- 
ternal abdominal  ring,  and  therein 
differs  from  varicocele. 

Treatment. — The  treatment  of  in- 
guinal hernia  is  identical  with  the 
treatment  described  for  hernia  in  gen- 
eral. The  incision  should  be  made 
directly  upward  in  order  to  avoid  the 
epigastric  artery,  which  will  be  upon 
the  inner  or  outer  side  of  the  neck 
according  as  the  hernia  is  oblique  or 
direct.  As  it  is  often  difficult  to  decide 
which  variety  of  inguinal  hernia  exists, 
the  position  of  the  epigastric  artery  is 
uncertain,  hence  incision  directly  up- 
ward is  safest.  If  an  undescended  tes- 
ticle lies  in  the  groin  and  is  a  compli- 
cation of  strangulated  hernia,  nt  may 
be  necessary  to  excise  the  testicle  at 
the  time  herniotomy  is  done.  Indeed, 
such  excision  may  be  demanded  in  the 
treatment  of  reducible  hernia  accompanied  by  undescended  testicle,  in 
order  to  make  it  possible  for  the  patient  to  endure  the  pressure  of  a 
truss  in  this  region. 

Femoral  Hernia. 


Irreducible  inguinal  hernia  showing 
concave  moulded  pad,  which  is  already 
applied  on  right  side.     (Bryant.) 


Anatomy  and  Pathology. — Femoral  hernia  is  never  congenital,  and 
occurs  in  women  more  often  than  in  men.  The  protruding  viscera  escape 
from  the  abdomen  into  the  sheath  of  the  femoral  vessels.  Usually  the 
exit  is  made  internally  to  the  femoral  vein  through  what  is  called  the 
internal  femoral  ring.  The  descending  intestine  then  follows  the  femoral 
canal  and  comes  out  upon  the  thigh  at  the  saphenous  opening,  also  called 
external  femoral  ring.  If  the  tumor  increases  it  turns  up  over  the  falci- 
form process  of  the  fascia  lata  and  lies  just  below  or  may  even  overlap  Pou- 
part's  ligament.  In  the  latter  case  the  tumor  lies  beneath  the  integument 
upon  the  aponeurosis  of  the  external  oblique  muscle  of  the  abdomen,  but 
the  neck  of  the  sac  is  at  the  internal  femoral  ring.  This  ring  or  opening 
is  situated  below  Poupart's  ligament  above  the  horizontal  ramus  of  the 
pubic  bone,  where  this  bone  is  covered  by  the  pectineus  muscle.  Toward 
the  middle  line  the  ring  is  bounded  by  the  sharp  edge  of  Gimbernat's 
ligament,  while  on  the  outer  side  it  is  separated  from  the  common  femoral 
vein  by  a  thin,  fibrous  partition  w'ithin  the  sheath  of  the  femoral  vessels. 
Sometimes  the  hernia  lies  in  the  femoral  canal  and  does  not  escape  at  the 
external  femoral  ring  or  saphenous  opening.  It  is  then  an  incomplete 
femoral  hernia. 

There  are  no  structures  of  importance  on  the  inner  and  upper  sides  of 
the  neck  of  the  hernial  sac. 

When  the  obturator  artery,  as  an  anomaly,  takes  its  origin  from  the 
deep  epigastric  artery,  it  occasionally  curves  around  the  inner  side  of  the 
neck  of  the  sac.  It  is  then  in  danger  of  being  wounded  in  the  operation 
of  herniotomv,  when  the  stricture  at  the  neck  of  the  sac  is  divided. 


SPECIAL    HERNIAS.  629 

The  coverings  of  a  complete  femoral  hernia  are  skin,  superficial  fascia, 
cribriform  fascia,  anterior  layer  of  the  sheath  of  the  femoral  vessels,  femoral 
septum,  subparietal  fat,  and  peritoneum 
(sacO.    These  coverings  ai-e  often  thinned  Fig.  396. 

so  that   the   hernia   seems  to  be  almost  ^,'  .^^.       '^^. 

directly  under  the  skin.     In  other  cases,         "^flr 

however,  the  coverings  are  thickened.    If         ,  \ 

the  hernia  is  incomplete  the  fascia  lata 
becomes  a  covering  in  place  of  the  cribri- 
form fascia.  When  strangulation  occurs 
in  femoral  hernia  the  stricture  is  either 
at  the  saphenous  opening,  at  Gimber- 
nat's  ligament,  or  at  the  neck  of  the  sac. 

Diagnosis. — Femoral  hernia  presents  m  i 

the  ordinary  symptoms  of  hernia.     The  ' 

tumor   is  usually  small,  tense,   globular  Femoral  hernia.    (Brtaxt.) 

or  ovoidal  in  shape,  and  situated  below 

Poupart's  ligament,  with  its  long  diameter  transverse  or  oblique.  The 
neck  of  the  sac  is  felt  to  be  external  to  the  pubic  spine,  which  distin- 
guishes it  from  inguinal  hernia,  in  which  the  neck  of  the  sac  is  internal 
to  the  pubic  spine.  Occasionally  a  femoral  hernia  may  be  as  large  as 
a  fist,  and  in  such  cases,  as  has  been  described,  it  turns  upward  and 
overlaps  Poupart's  ligament  in  a  way  which  causes  it  to  resemble  an 
inguinal  hei*nia.  The  essential  point  in  the  diagnosis  of  these  large 
femoral  hernias  from  inguinal  hernias  is  the  position  of  the  neck  of  the 
hernia  relative  to  the  spine  of  the  pubes.  The  neck  is  outside  of  the 
spine  in  femoral  hernia.  A  femoral  hernia  never  attains  the  immense 
size  that  is  possible  in  inguinal  hernia. 

A  group  of  enlarged  lymphatic  glands  about  the  saphenous  opening 
may  resemble  a  femoral  hernia.  If  a  small  femoral  hernia  is  overlaid 
by  enlarged  glands  the  hernia  may  escape  notice  even  when  symptoms 
of  strangulation  are  present.  Suspicious  symptoms  occurring  in  such  a 
case  should  cause  an  exploratory  operation  to  be  instituted. 

A  psoas  abscess  pointing  in  the  groin  gives  rise  to  a  swelling  near  to 
the  site  of  femoral  hernia.  In  such  cases  the  tumefaction  is  usually  out- 
side of  the  femoral  vessel  instead  of  inside,  as  in  hernia.  There  is  some 
fulness  in  the  iliac  fossa,  the  tumor  shows  some  fluctuation,  and  there  is 
often  evidence  of  tubercular  disease  in  the  spinal  column. 

Varicosity  of  the  saphenous  vein  may  give  rise  to  a  small  tumor  in  the 
neighborhood  of  the  saphenous  opening.  It  presents  the  characteristic 
tortuosity  of  varicose  veins,  and  will  probably  be  associated  with  a  vari- 
cose condition  down  the  inner  side  of  the  thigh. 

Treatment. — Reducible  femoral  hernias  should  be  reduced  and  the 
recurrence  of  protrusion  prevented  by  wearing  a  truss. 

Operations  for  a  radical  cure  are  not  likely  to  be  successful,  because  the 
internal  femoral  ring  has  rigid  borders  not  readily  sutured  with  satisfac- 
tory results.  In  strangulated  femoral  hernia  taxis  should  be  undertaken 
Avith  the  thigh  slightly  flexed  upon  the  pelvis,  adducted,  and  rotated 
inward,  in  order  to  relax  the  falciform  edge  of  the  saphenous  opening. 
If  the  tumor  is  large  pressure  should  be  directed  downward  before  the 
hernia  is  pushed  upward  and  backward.  As  in  all  hernias,  lifting  up  the 
tumor  so  as  to  draw  a  little  more  intestine  out  through  the  ring  is  often  a 
good  preliminary  manipulation.    In  reducing  the  hernia  it  must  be  recol- 


630  DISEASES    OF    THE     ABDOMEN    AND    PELVIS. 

lected  that  the  p^rtiou  of  the  gut   which   has  protruded    la.st  must  be 
pushed  into  tlie  ab(h)men  first. 

Etherization,  oi)iun),  and  hot  baths  are  not  very  efficacious  in  aiding 
the  reduction  of  strangulated  femoral  hernia ;  hence,  early  operation  is 
demanded  in  cases  that  do  not  yield  to  moderate  taxis.  The  incision 
should  be  a  vertical  one.  The  skin  over  the  hernia  is  usually  pinched 
up  in  a  fold  and  laid  open  by  transfixion,  because  the  thinness  of  the 
coverings  renders  an  incision  made  by  puncture  from  the  exterior  a  little 
dangerous.  The  point  of  strangulation  is  discovered  by  the  tip  of  the 
finger  after  opening  the  sac.  It  is  usually  necessary  to  open  the  sac  in 
operations  for  strangulated  femoral  hernia,  since  relief  of  the  strangula- 
tion without  opening  the  sac  is  not  often  possible  in  femoral  herniotomy. 
The  strangulating  band  should  be  divided  by  incision  inward  and  upward. 
Several  shallow  notches  are  better  than  one  deep  one,  since  there  is  less 
possibility  of  injuring  an  abnormal  obturator  artery,  which  might  be 
present,  curving  round  the  neck  of  the  sac  or  along  the  edge  of  Gimber- 
nat's  ligament.  The  occasional  abnormal  course  of  this  artery  renders 
the  use  of  a  quite  dull  hernia  knife  judicious  at  this  stage  of  the  opera- 
tion, since  the  arterial  wall  is  less  liable  to  be  injured  with  a  dull  knife 
than  with  a  sharp  one.  The  dense  fibrous  tissue  causing  the  stricture  is 
readily  sawed  through  with  a  dull  edge.  Sometimes  the  surgeon  can 
feel  the  artery  beating  as  he  pushes  the  tip  of  his  finger  against  the  edge  of 
Gimbernat's  ligament.  Under  such  circumstances  incision  of  qr  notching 
Gimbernat's  ligament  close  to  the  pubic  bone  is  less  liable  to  do  damage 
than  the  ordinary  cut  upward  and  inward.  It  is  said  that  incision 
directly  inward  is  not  so  satisfactory  as  one  directly  inward  and  upward, 
since  it  is  apt  to  make  a  larger  wound,  and  causes  difficulty  in  restraining 
the  hernia  afterward  by  means  of  a  truss. 


Umbilical  Hernia. 

A  hernia  occurring  at  the  navel  is  termed  an  umbilical  hernia.  It 
occurs  in  infants  through  the  umbilical  ring,  and  in  adults  either  close  to 
or  at  the  opening.  This  form  of  hernia  is  most  frequent  in  infants  and 
in  old,  corpulent  women.  The  hernial  sac  is  thin  and  often  full  of  holes. 
The  contents  of  the  sac  are  omentum  with  perhaps  some  coils  of  intestines 
wrapped  up  in  it.  The  coverings  of  an  umbilical  hernia  are  skin,  super- 
ficial fascia,  transversalis  fascia,  and  peritoneum  (sac).  Very  often  these 
coverings  are  so  thin  that  there  is  scarcely  anything  outside  of  the  hernia 
but  the  skin  and  the  peritoneum.  In  adults  this  hernia  may  become  very 
large  and  it  is  frequently  more  or  less  irreducible.  Obstruction  is  not 
uncommon  ;  strangulation  is  comparatively  rare.  In  infants  the  condi- 
tion is  often  cured  spontaneou.sly.  Nevertheless  it  is  wise  to  keep  the 
hernia  reduced  by  placing  over  the  umbilicus  a  pad  held  in  place  by 
means  of  adhesive  plaster  or  bandage.  A  large  coin  or  a  piece  of  cork 
wrapped  up  in  an  adhesive  plaster  with  the  adhesive  side  out  may  be 
applied  with  great  satisfaction.  The  adhesive  surface  of  the  plaster  keeps 
the  coin  from  slipping,  and  a  broad  strip  of  adhesive  plaster  carried  over 
the  whole  with  the  ends  fixed  at  the  back  makes  a  convenient  dressing. 
The  plano-convex  disk  of  yellow  wax  used  by  seamstresses  for  waxing 
thread  makes  a  good  pad  and  the  wax  adheres  well  to  the  child's  skin. 
In  adults  an  umbilical  truss  or  an  elastic  bandage  should  be  applied. 

If  strangulation  occurs  an  incision  for  the  relief  of  the  stricture  is 


SPECIAL    HERNIAS.  631 

demanded.  The  external  wound  may  be  made  over  the  top  of  the  tumor, 
or  at  one  side  close  to  the  neck  of  the  sac.  From  the  latter  position  the 
surgeon  can  often  work  under  the  growth  and  relieve  the  stricture  with 
very  little  disturbance.  It  does  not  make  very  much  difference  in  what 
direction  the  constricting  band  is  divided,  as  there  are  no  structures  of 
importance  around  the  umbilical  aperture.  An  upward  incision,  how- 
ever, is  probably  the  most  desirable.  Division  of  the  band  may  be  made 
in  some  cases  without  opening  the  sac. 

If  it  is  necessary  to  open  the  sac  great  care  should  be  taken,  because 
the  coverings  are  so  thin  that  the  intestine  may  be  suddenly  and  unex- 
pectedly wounded.  The  protruding  omentum  should  be  ligated  and 
excised,  after  which  the  stump  should  be  returned.  Any  portion  of  intes- 
tine hidden  from  view  by  thickened  omentum  should  be  carefully  searched 
for,  since  the  strangulation  of  gut  may  be  unrelieved  unless  the  intestine 
is  fully  inspected.  After  the  strangulation  has  been  overcome  and  the 
sac  excised,  the  edges  of  the  ring  should  be  freshened  and  sutured  with 
silk  sutures. 

In  large  umbilical  hernias  and  in  those  giving  trouble  because  of  their 
irreducibility  or  tendency  to  become  obstructed,  radical  operation  is  jus- 
tifiable. This  is  scarcely  judicious  in  small  umbilical  hernias,  which  are 
easily  controlled  by  trusses. 


CHAPTER     XXII. 

DISEASES  OF  THE  RECTUM. 

Pathology. — Certain  congenital  malformations  of  the  anus  and  roctuiu 
require  operative  treatment.  These  congenital  deformities  are  ordinarily 
discovered  soon  after  the  birth  of  the  child,  by  the  absence  of  intestinal 
discharge  and  by  the  occurrence  of  vomiting.  The  anus  may  be  entirely 
occluded,  or  it  may  be  represented  by  a  minute  orifice  through  which  the 
meconium  and  feces  are  not  effectually  expelled.  In  other  cases  the  anus 
may  be  entirely  absent,  and  the  skin  between  the  buttocks  not  even 
dimpled  in  the  anal  region.  The  partition  between  the  surface  and  the 
end  of  the  rectal  pouch  varies  in  such  ca.ses  from  a  quarter  of  an  inch  to 
an  inch  in  thickness.  If  the  occluding  tissue  is  thin  it  may  Inilge  down 
when  the  child  cries,  and  transmit  to  the  eye  the  dark  color  of  the  meco- 
nium on  the  other  side ;  thereby  indicating  that  it  is  of  no  con.siderable 
thickness. 

In  some  cases  the  anus  is  perfectly  formed,  and  it  is  only  by  the  intro- 
duction of  a  probe,  or  the  finger,  that  the  nurse  or  the  surgeon  discovers 
that  the  exterior  orifice  has  no  connection  with  the  rectum  above.  In 
still  other  instances,  the  whole  rectum  may  be  absent,  and  the  large  bowel 
terminate  in  a  blind  pouch  at  the  top  of  the  sacrum,  or  at  a  still  higher 
point.  In  these  cases  the  anus  is  usually  imperforate,  that  is,  absent. 
Clinically,  it  may  be  impossible  to  tell  a  case  of  simple  imperforate,  or 
absent,  anus  from  a  case  of  imperforate  anus  complicated  or  associated 
with  imperforate  rectum.  It  is  readily  seen  that  if  the  anus  is  absent  the 
surgeon  has  no  means  of  discovering  whether  the  rectum  is  present  or 
absent,  unless  examination  of  the  external  surface  of  the  abdomen  gives 
indications  of  a  swelling  due  to  retention  of  the  intestinal  contents  in  a 
colon  which  has  no  lower  outlet. 

Treatment. — The  operative  treatment  in  these  cases  consists  in  dis- 
secting from  the  perineum  toward  the  rectum,  with  a  view  of  establishing 
an  outlet  for  the  meconium  and  feces.  If  only  a  thin  diaphragm  causes 
the  obstruction,  a  crucial  incision  liberates  the  retained  contents  and  con- 
verts the  deformity  into  a  normal  condition.  Operation  under  such  cir- 
cumstances is  unattended  with  shock,  and  the  functions  are  soon  normally 
performed.  If  a  comparatively  deep  dissection  is  required  to  find  the 
lower  end  of  the  bowel,  the  operation  is  a  serious  one  and  may  terminate 
fatally  from  shock.  Under  such  circumstances,  a  straight  incision  is 
made  from  behind  the  scrotum  to  the  point  of  the  coccyx,  and  gradually 
deepened  backward  and  upward,  following  the  line  of  the  coccygeal  curve. 
Caution  is  required  to  avoid  injuring  the  bladder.  Excision  of  the  coccyx 
has  been  advocated  in  order  to  gain  room  for  such  operative  manipula- 
tion when  the  lower  end  of  the  rectum  is  situated  at  a  high  point. 

Some  authorities  advise  that  when  the  bowel  is  found,  an  attempt  should 
be  made  to  draw  it  down  and  to  stitch  its  wall  to  the  skin.  This  can 
seldom  be  accomplished  if  the  distance  is  great ;  and  as  it  is  a  somewhat 
dangerous  operative  procedure  under  such  circumstances,  it  is  probably 


INFLAMMATION    OF     THE     RECTUM.  633 

best  not  to  attempt  it.  If  a  dissection  extending  from  an  inch  to  an  inch 
and  one-half  upward  does  not  enable  the  operator  to  find  the  rectum,  iliac 
colotomy  on  the  left  side  of  the  abdomen  is  the  proper  operation.  If  it  is 
uncertain  whether  the  descending  colon  is  properly  developed,  colotomy 
above  the  right  groin  is  to  be  done. 

The  rectum  or  colon  occasionally  opens  into  the  bladder,  urethra,  or  the 
vagina,  or  upon  the  surface  of  the  body,  at  some  distance  from  the  anal 
region.  In  such  congenital  deformities  an  attempt  should  be  made  to 
open  the  normal  route  to  the  intestines  from  the  anal  region;  when  this 
has  been  done  successfully  the  abnormal  opening  will  close  spontaneously, 
or  may  be  occluded  by  plastic  operation.  If  it  is  impossible  to  construct 
a  canal  from  the  anus  to  the  bowel  when  the  rectum  opens  into  the  bladder, 
it  is  proper  to  make  a  perineal  incision  into  the  posterior  urethra,  in 
order  to  permit  free  escape  of  the  intestinal  contents.  If  the  rectum 
opens  into  the  vagina  by  a  large  orifice,  operation  may  be  deferred  until 
the  child  is  tw^o  or  three  years  old. 

After  constructing  new  openings  for  the  escape  of  feces,  in  cases  of  con- 
genital malformation  of  the  anus  and  rectum,  the  surgeon  must  use  rectal 
bougies,  or  have  the  mother  insert  her  finger,  daily,  in  order  to  prevent 
cicatricial  stricture. 

Pruritus  of  the  Anus. 

Pathology  and  Symptoms. — Pruritus,  or  itching,  of  the  anus  is  usu- 
ally most  troublesome  at  night.  It  may  be  due  to  lice,  to  the  vegetable 
parasite  causing  eczema  marginatum,  to  thread-worms,  to  a  papular  erup- 
tion about  the  anus,  or  it  may  be  secondary  to  uterine  disease.  In  some 
cases  the  gouty  diathesis  is  probably  a  predisposing  cause.  The  symp- 
toms are  violent  itching,  making  it  often  impossible  for  the  patient  to 
abstain  from  scratching,  while  locally  there  is  little  or  no  cause  for  the 
troublesome  affection,  except  perhaps  a  little  redness  of  the  skin.  In  old 
cases  there  may  be  enlargement  of  the  cutaneous  folds  at  the  anal  open- 
ing, and  the  skin  is  thickened  and  discolored  by  prolonged  inflammation, 
due  to  scratching.  Hemorrhoidal  tumors  may  be  associated  with  anal 
pruritus. 

Treatment. — Anal  pruritus  is  to  be  treated  by  removing  the  cause, 
and  by  keeping  the  bowels  open,  and  the  parts  well  w^ashed.  It  is  impor- 
tant that  after  washing,  the  skin  should  be  thoroughly  dried  by  a  soft 
towel  or  absorbent  cotton  without  rubbing  the  skin,  since  the  least  rubbing 
may  start  an  attack  of  itching,  w^hich  will  be  followed  by  scratching. 
Carbolic  acid  is  probably  the  best  application  to  relieve  the  intense  itch- 
ing. It  may  be  used  in  a  lotion  containing  from  10  to  20  grains  of  car- 
bolic acid  to  the  ounce  of  water,  with  which  a  little  glycerin  is  mixed. 
About  5  grains  of  fused  potassa  may  at  times  be  added  to  the  ounce  of 
liquid  with  advantage.  Tar  ointment  and  sulphur  ointment  are  also 
valuable.  Arsenic  given  internally  seems  at  times  serviceable.  If  the 
disease  is  manifestly  due  to  a  gouty  tendency,  colchicum,  a  properly  regu- 
lated diet,  and  exercise  are  important  adjuvants.  Relief  has  sometimes 
been  obtained  by  introducing  a  conical  bougie  into  the  rectum. 

Inflammation  of  the  Rectum. 

The  normal  pouches  of  the  mucous  membrane  of  the  rectum  sometimes 
become  enlarged  and  distended,  owing  to  protracted  retention  of  the  feces. 


634  DISEASES    OF    THE    RECTUM. 

This  condition  causes  jjain  and  itchin<r  in  the  rectal  region.  There  is  in 
this  disease,  however,  no  spasm  of  the  sj)hincter,  such  as  occurs  in  anal 
fissure. 

The  treatment  con.sists  in  drawing  down  the  enlarged  pouches  with  a 
blunt  hook  and  clipping  off"  the  folds  of  mucous  membrane,  so  that  the 
fecal  matter  cannot  be  retained. 

Inflammation  of  the  mucous  membrane  of  the  rectum  is  called  proc- 
titis, and  is  a  medical  rather  than  a  surgical  condition,  unless  ulceration 
occurs.  It  may  be  due  to  gonorrhoea,  to  the  use  of  the  leaves  of  the 
poison  ivy  for  cleansing  the  anus  after  defecation,  and  to  foreign  bodies 
inserted  into  the  rectum.  The  symptoms  are  somewhat  similar  to  dysen- 
tery. Tenesmus,  rectal  pain,  and  the  discharge  of  bloody  mucus,  or  of 
pus,  are  indicative  of  proctitis. 

The  treatment  consists  in  removing  the  cause,  and  in  the  use  of  mild 
astringent  injections,  such  as  nitrate  of  silver  (2  or  o  grs.  to  the  ounce  of 
water),  or  sulphate  of  zinc  (5  grs.  to  the  ounce),  or  in  the  introduction 
of  suppositories  of  an  anodyne  and  astringent  composition. 

Foreign  Bodies  in  the  Rectum. 

Indigestible  articles  which  have  been  swallowed  may  become  impacted 
in  the  rectum,  because  their  exit  is  prevented  by  the  sphincter  muscle. 
On  the  other  hand,  foreign  bodies  may  be  pushed  into  the  rectum  through 
the  sphincter  by  the  individual  himself,  as  a  curious  sort  of  masturbation, 
or  by  others  during  the  patient's  unconsciousness  from  alcohol.  Articles 
of  extraordinary  size,  such  as  turnips,  bottles,  and  earthen  jars  have  thus 
been  put  in  the  rectum.  Chronic  iuflamraation  of  the  rectum  may  be 
set  up  by  foreign  bodies,  and,  at  times,  simulate  malignant  disease  of  the 
part.  Such  foreign  materials  are  to  be  removed  by  means  of  forceps,  or 
the  fingers,  after  etherization  of  the  patient  and  dilatation  of  the  sphinc- 
ter muscle.  In  some  cases,  where  the  foreign  body  is  large,  it  has  been 
necessary  to  deliver  it  with  obstetric  forceps.  Incision  of  the  sphincter 
muscle  is  justifiable  if  sufficient  dilatation  to  permit  extraction  is  impos- 
sible. 

Impacted  Feces. 

Dilatation  of  the  rectum  is  not  unusual  in  old  persons ;  and  in  this 
pouch-like  dilatation  fecal  masses  may  remain  and  become  compressed 
into  a  large,  hard  mass,  which  it  is  impossible  for  the  muscular  wall  of 
the  stretched  rectum  to  expel  through  the  anus.  The  irritation  from  the 
retained  fecal  masses  may  give  rise  to  a  mucous  discharge  which,  becom- 
ing stained  with  fecal  matter,  causes  the  patient  to  think  that  he  is  suffer- 
ing from  diarrhoea. 

The  diagnosis  of  impacted  feces  can  only  be  made  with  certainty  by 
examination  with  the  finger  introduced  through  the  anus. 

The  symptoms  are  pain,  tenesmus,  and  chronic  constipation ;  this  last 
symptom,  however,  is  concealed  in  cases  where  the  diarrhcea-like  discharge, 
spoken  of  above,  occurs.  Laxatives  and  cathartics  can  be  of  no  service 
in  cases  of  impacted  feces,  because  the  condition  is  mechanical  and  it  is 
impossible  for  the  large  mass  to  be  extruded  through  the  normal  orifice  ; 
therefore,  it  must  be  broken  up  by  means  of  instruments  introduced 
through  the  anus.  The  handle  of  a  spoon,  or  a  pair  of  forceps,  by  which 
the  mass  may  be  perforated  and  disintegrated,  is  an  efficient  aid  to  the 


PROLAPSE    OF    THE    RECTUM.  635 

surgeon's  fingers.  Repeated  and  copious  injections  of  warm  water  and 
oil  into  the  bowel  will  aid  in  softening  and  removing  the  mass  thus  broken 
into  pieces. 

Prolapse  of  the  Rectum. 

Pathology  and  Symptoms. — By  prolapse  of  the  rectum  is  meant  pro- 
trusion of  more  or  less  of  that  portion  of  the  intestine  in  a  healthy  condi- 
tion, and  not  the  mere  pushing  out  of  the  mucous  membrane,  which 
occasionally  occurs  in  connection  with  hemorrhoids.  The  mucous  mem- 
brane of  the  rectum  is  loosely  attached  to  the  muscular  coat,  and  there- 
fore an  inch  or  two  of  the  mucous  membrane  may  project  through  the 
anus  without  any  change  of  location  of  the  rest  of  the  bowel.  This  pro- 
lapse of  the  mucous  membrane  alone  is  called  partial  prolapse  of  the 
rectum  ;  whereas  the  term  complete  prolapse  is  applied  when  the  rectum 
is  turned  inside  out,  as  it  were,  by  a  process  of  invagination,  and  all  the 
coats  form  the  external  tumor. 

Partial  prolapse  is,  of  necessity,  limited  in  extent,  because  the  amount 
of  sliding  between  the  coats  is  not  indefinite.  In  complete  prolapse,  how- 
ever, almost  any  length  of  the  intestinal  tube  may  be  found  external  to 
the  anus.  The  disease  is  most  common  in  children  and  in  aged  persons, 
and  is  due  to  a  weakened  condition  of  all  the  tissues,  although  the  ex- 
citing cause  is  straining.  Stone  in  the  bladder,  urethral  stricture,  phi- 
mosis, dysentery,  chronic  constipation,  and  polypus  in  the  rectum  may 
be  causes,  because  of  the  abdominal  straining  and  bearing-down  which 
they  induce. 

The  diagnosis  is  very  clear  when  complete  prolapse  of  the  rectum 
occurs.  The  smooth  folds  of  the  mucous  membrane  on  the  outside  of 
the  sausage-like  tumor  are  characteristic.  There  is  a  groove  around  the 
mass  at  the  site  of  the  sphincter  muscle. 

Partial  prolapse  presents  some  resemblance  to  a  mass  of  internal  hem- 
orrhoids, but  has  not  the  bunched  appearance  that  is  exhibited  by  the 
purplish  piles  and  the  prolapsed  mucous  membrane  accompanying  them. 
Rectal  polypus,  when  protruding  from  the  anus,  is  harder  than  prolapsed 
intestine,  and  has  a  distinct  pedicle. 

The  prolapsed  tissues  at  first  appear  outside  the  anus  only  after  stool, 
but  repetition  of  the  protrusion  occurs,  and  finally  the  disease  may  be- 
come so  aggravated  that  the  intestine  is  protruded  outside  of  the  body 
whenever  the  patient  walks  or  assumes  the  upright  position.  The  anus  by 
this  time  has  become  so  dilated  that  retention  in  the  rectum  is  almost  im- 
possible. Sometimes  the  protruded  gut  becomes  strangulated  by  the 
sphincter,  but  this  is  more  apt  to  occur  in  the  earlier  than  in  the  later 
stages. 

Treatment. — The  prolapsed  rectum  must  be  reduced  when  it  first 
occurs  by  gentle,  though  firm,  pressure  with  the  fingers  after  anointing 
the  protruded  gut  with  some  oleaginous  preparation.  During  the  reduc- 
tion the  patient  should  assume  the  knee-elbow  position,  or  be  placed  in  a 
recumbent  position  upon  one  side.  In  the  case  of  infants  it  answers  well 
to  place  the  child  upon  its  abdomen  across  the  lap  of  the  nurse.  Steady 
pressure  may  be  required  for  several  minutes.  It  is  evident  that  the  por- 
tion of  the  intestine  which  has  been  protruded  last  must  be  pushed  up 
first.  If  these  manipulations  fail,  reposition  may  often  be  obtained  by 
introducing  the  finger,  covered  with  a  piece  of  lint,  into  the  orifice  of  the 
protruded  bowel  and  pushing  it  slowly  upward  into  the  intestine.    During 


636  DISEASES    OF    THE    RECTUM. 

this  manipulatiun  tlie  lint  adheres  to  the  mucous  memhrane,  carrying  it 
upward  so  that  the  invaginated  bowel  is  drawn  back  into  tlie  normal 
position.  The  finger  is  then  witlidrawn,  and,  subsequently,  the  lint  is 
pulled  out. 

Support  to  the  perineum  an<l  to  the  rectum  should  be  given  after 
reduction  by  applying  a  T-bandage,  which  is  a  piece  of  muslin  carried 
around  the  perineum  and  attached  to  a  belt  in  front  and  behind.  After 
having  reduced  a  prolapsed  rectum  in  an  infant,  I  have  gained  sup- 
port by  passing  a  deep  suture  through  the  tissues  at  the  verge  of  the 
anus,  thus  narrowing  the  orifice.  If  the  prolapsed  rectum  is  strangu- 
lated by  the  sphincter,  it  may  be  necessary  to  dilate  or  cut  that  msucle, 
in  order  to  prevent  the  occurrence  of  gangrene  and  permit  the  replace- 
ment of  the  gut. 

To  ])revent  the  recurrence  of  prolapse  after  reduction  requires  a  great 
deal  of  careful  treatment.  The  patient  should  never  be  allowed  to 
assume  the  sitting  position  when  evacuating  the  contents  of  the  bowels. 
He  should  be  compelled  to  defecate  when  lying  down  upon  the  side,  or 
in  a  standing  position.  If  the  anus  is  drawn  a  little  to  one  side  with 
the  fingers  as  the  fecal  material  is  being  evacuated,  the  tendency  to 
prolapse  is  greatly  diminished.  The  bowels  should  be  kept  in  such  a 
condition  that  constipation  and  the  evacuation  of  hard  masses  may  be 
avoided,  since  all  straining  is  dangerous.  Broad  strips  of  adhesive 
plaster  carried  across  the  buttocks,  so  as  to  hold  the  two  nates  close 
together,  is  quite  an  efficient  means  of  giving  support  to  the  rectum  in 
small  children.  Astringent  ointments  or  suppositories,  such  as  tannic 
acid  (30  grains  to  the  ounce),  may  be  found  effective ;  or  astringent 
enemas  containing  zinc  sulphate,  alum,  or  similar  preparations,  or  rectal 
injections  of  cold  water,  may  be  substituted  for  the  ointments  or  sup- 
positories, (xlycerin  suppositories  w'ill  probably  be  found  valuable  in 
keeping  the  bowels  open  without  producing  straining.  Under  such  a 
line  of  treatment  cases  occurring  in  infancy,  and  cases  of  moderate 
severity  in  adults,  will  probably  be  cured  in  a  few  mouths.  The  more 
inveterate  cases  require  surgical  treatment. 

If  there  is  a  small  mass  of  mucous  membrane  protruding  from  the 
anus,  and  no  prolapse  of  the  other  coats  of  the  bowel,  a  pair  of  scissors 
may  be  used  to  trim  away  the  redundant  tissue,  in  the  hope  that  the 
resultant  cicatricial  contraction  will  produce  cure.  In  more  severe  cases 
fuming  nitric  acid  may  be  applied  to  the  mucous  membrane  of  the 
intestines,  so  as  to  produce  sloughing  and  cicatricial  contraction.  The 
agent  should  be  thoroughly  applied  to  the  entire  surface  of  the  pro- 
truded part  of  the  intestine,  excepting  a  circular  strip  extending  about 
half  an  inch  above  the  anus.  Another  method  is  clamping,  with  a 
hemorrhoid  clamp,  a  longitudinal  portion  of  the  mucous  membrane, 
which  is  subsequently  cut  off  and  the  stump  seared  with  the  red-hot 
cautery  iron.  Three  or  four  such  longitudinal  folds  may  be  removed. 
The  operation  will  result  in  cicatricial  contraction  of  the  dilated  gut ; 
and  by  the  adhesions  produced  between  the  rectal  wall  and  surrounding 
tissues  the  tendency  to  prolapse  is  prevented. 

The  orifice  of  the  anus,  which  has  become  dilated  in  all  chronic  cases, 
may  be  reduced  by  cutting  out  a  V-shaped  portion  of  the  sphincter 
at  the  posterior  part  or  at  the  sides,  and  thus  cause  retention  of  the 
relaxed  rectal  structures.  I  have  recently  operated  with  satisfaction  on 
a  bad  case  of  this  affection  by  cutting  out  V-shaped  portions  of  the 
sphincter  and  of  the  entire  posterior  wall  of  the  rectum  ;    the  two  tri- 


HEMORRHOIDS. 


637 


angles  having  a  common  base  at  the  back  of  the  anal  opening.  Catgut 
sutures  were  then  applied  within  the  gut  so  as  to  bring  its  divided  walls 
together  and  through  the  sphincter  muscle  and  skin  externally.  This 
somewhat  resembles  the  method  of  DiefFenbach. 


Fig.  397. 


;?;;s5  TUBEROSITY 


COCCYX 

Author's  method  of  oi^eratiug  for  prola}3se  of  rectum. 

Where  no  operation  will  be  permitted  by  the  patient  a  certain  amount 
of  comfort  may  be  obtained  by  wearing  an  anal  truss.  This  consists  of 
a  belt,  to  which  is  attached  a  spring  going  between  the  buttocks  and 
holding  a  pad  against  the  anus. 


Fig. 


Hemorrhoids. 

Pathology. — The  term  hemorrhoid  or  pile  is  applied  to  several  varie- 
ties of  tumors  about  the  verge  of  the  anus.  Unfortunately,  this  want 
of  accuracy  in  the  use  of  the  term  creates  confusion  in  the  pathology 
and  treatment  of  anal  conditions.  It  would  be  better  if  the  tumors 
called  internal  hemorrhoids  were  the  only  ones  to  which  the  name  hemor- 
rhoid was  applied;  while  to  the  various  affections  called  external  hemor- 
rhoids better  descriptive  names  might  be  given. 

An  internal  hemorrhoid  is  a  vascular  tumor  or  angeioma,  situated 
beneath  the  mucous  membrane  of  the  , 
lower  portion  of  the  rectum,  and  usu- 
ally not  higher  than  one  or  two  inches 
from  the  anus ;  ordinarily,  these 
tumors  lie  just  within  the  anal  open- 
ing- 

The  dilated  veins,  capillaries,  and 
small  arteries  constituting  the  essential 
structure  of  the  pile  may  be  held  to- 
gether by  so  much  thickened  connect- 
ive tissue  as  to  give  the  tumor  quite 
a  hardened  consistence.  Repeated 
attacks  of  inflammation  have  a  ten- 
dency to  increase  the  cellular  connect- 
ive tissue  and  to  obliterate  some  of 
the    vascular  channels,  and    thereby 

increase  the  bulk  and  hardness  of  the  tumor.     Prolapse  of  the  mucous 
membrane  in  the  region  of  the  hemorrhoidal  tumor  may  also  occur  through 


Internal  hemorrhoids  "with  prolapse  of 
mucous  membrane.     (Treves.) 


638  DISEASES    OF    THE    RECTL'M. 

the  anus  and  increase  the  bulk  of  the  mass.  The  essential  components 
of  an  internal  pile,  however,  are  the  dilated  vascular  channels  and  the 
accompanying;  cavernous  structure,  which  perhaps  may  be  in  part  a 
new  formation. 

Anything  tending  to  increase  the  blood  pressure  about  the  lower  end 
of  the  rectum  may  cause  internal  hemorrhoids.  Obstruction  to  circula- 
tion arising  from  disease  of  the  heart,  lungs,  or  liver,  or  from  an  over- 
loaded colon,  may  all  give  rise  to  hemorrhoids.  Downward  pressure  u])on 
the  pelvic  contents  by  contraction  of  the  diaphragm  and  abdominal 
muscles  increases  the  congestion  in  the  inferior  hemorrhoidal  vessels.  It 
is  this  mechanism  which  gives  rise  to  hemorrhoids  in  cases  of  enlarged 
prostate  gland,  stricture  of  the  urethra,  stone  in  the  bladder,  phimosis, 
carcinoma  or  stricture  of  the  rectum,  and  in  prolonged  and  frequent 
straining  at  stool. 

.Symptoms. — The  presence  of  hemorrhoidal  tumors  in  the  rectum  gives 
rise  to  pain,  itching,  a  feeling  of  weight,  tenesmus,  and  other  symptoms 
of  discomfort.  Pain,  in  fact,  may  radiate  to  the  genital  organs  and  in 
other  directions.  At  first  these  symptoms  are  not  very  marked,  but  after 
a  time  they  increase,  and  there  is  a  tendency  for  the  tumors  to  protrude 
through  the  anus  when  the  patient  is  at  stool.  This  will  require  him  to 
use  his  fingers  to  replace  the  growths  within  the  rectum.  Later  the  ten- 
dency to  prolapse  becomes  more  marked  and  is  more  constant.  Finally, 
it  is  not  unusual  for  a  portion  of  the  mucous  membrane  of  the  bowel  to 
be  prolapsed  with  the  hemorrhoids.  Such  a  protruding  mass  may,  by 
contraction  of  the  sphincter  muscle,  become  strangulated,  whereupon  it 
becomes  much  swollen  and  painful,  and  the  seat  of  inflammation.  Occa- 
sionally gangrene  of  the  protruding  portion  occurs;  and  if  it  is  too  large 
to  be  replaced  by  the  patient,  and  he  does  not  seek  competent  assistance, 
inflammation  of  the  piles  without  strangulation  may  occur  and  cause 
increased  rectal  symptoms. 

When  the  congestion  of  the  growths  becomes  very  great  during  strain- 
ing at  stool,  rupture  of  the  thinned  mucous  membrane  covering  the  dilated 
vessels  of  which  hemorrhoids  consist  may  cause  hemorrhage.  Sometimes 
the  bleeding  is  only  a  .slight  staining,  at  other  times  the  fecal  masses  are 
coated  with  blood  ;  while  on  still  other  occasions  there  may  be  a  spurting 
hemorrhage  of  several  ounces,  when  the  patient  endeavors  to  evacuate 
the  contents  of  the  bowels.  This  may  also  happen  when  there  is  no  fecal 
mass  extruded,  because  the  desire  to  go  to  stool  is  felt  from  the  swollen 
condition  of  the  mucous  membrane  of  the  rectum.  The  blood  which 
flows  from  hemorrhoids  is  redder  than  blood  which  has  escaped,  for  any 
cause,  from  the  bowels  higher  up  than  the  rectum,  since  the  latter  is 
altered  in  character  and  made  darker  by  intestinal  secretions. 

In  long-standing  disease  the  sphincter  becomes  relaxed  and  does  not 
resist  the  pressure  from  above,  and  allows  the  protrusion  of  the  piles  to 
exist  almost  constantly.  The  bleeding  often  relieves  the  pain  and  other 
local  symptoms,  but  if  occurring  frequently,  as  it  does  in  extreme  cases,  it 
will  lead  to  dangerous  ansiemia  of  the  patient. 

Diagnosis. — The  diagnosis  of  hemorrhoids  where  they  are  protruding 
is  simple  enough.  The  difference  between  this  disease  and  prolapse  of  the 
rectum  has  already  been  mentioned.  When,  however,  the  hemorrhoidal 
tumors  are  collapsed  and  not  distended  with  blood,  the  surgeon's  fingers 
may  scarcely  recognize  them.  A  diagnosis  must  then  be  made  by  careful 
examination  after  the  rectum  has  been  emptied  of  its  contents  by  enemas. 
The  patient,  while  lying  upon  his  side,  should  be  ordered  to  bear  do\vn 


HEMORRHOIDS.  639 

as  if  at  stool,  while  the  surgeon  draws  the  anus  open  with  his  fingers.  If 
hemorrhoids  exist  a  red  or  purplish  shining  tumor,  with  a  more  or  less 
irregular  surface,  will  protrude.  There  may  be  one  or  several  such  vas- 
cular masses.  Between  the  sphincter  and  the  tumors  there  is  usually  a 
deep  groove.  The  inner  surface  of  the  protruding  growth  usually  appears 
somewhat  bluer  than  the  surface  near  I  he  anus.  Such  tumors  may  sur- 
round the  anal  opening  like  a  rosette  and  at  some  portions  show  ulcera- 
tion from  which  bloody  serum  escapes. 

The  presence  of  a  tumor  protruding  from  the  anus  and  associated  with 
great  pain,  because  it  cannot  be  pushed  back  by  the  patient,  should  cause 
a  suspicion  of  hemorrhoids.  Even  if  this  pain  is  not  accompanied  with 
hemorrhage  an  ocular  examination  should  at  once  be  instituted. 

Treatment. — I  have  purposely  omitted  the  consideration  of  external 
hemorrhoids  because  the  condition  is  so  different  from  internal  hemor- 
rhoids, and  I  shall,  therefore,  at  this  point  speak  of  the  treatment  of 
internal  hemorrhoids  alone. 

Palliative  treatment  consists  in  carefully  regulating  the  bowels,  so  as 
to  keep  them  open,  and  so  prevent  the  rectum  from  becoming  blocked 
with  hardened  feces.  Alcoholic  stimulation  in  excess  and  other  errors  in 
regard  to  food  and  drink  may  often  lead  to  increased  discomfort  to  those 
subject  to  piles.  Compound  licorice  powder,  confection  of  senna,  saline 
cathartics,  and  other  laxatives  answer  very  well  for  regulating  the  condi- 
tion of  the  bowels.  Locally  the  patient  should  use  mild  astringent  oint- 
ments, which  should  be  applied  to  the  anus  and  pushed  up  into  the  rectum 
so  as  to  come  in  contact  with  the  mucous  membrane.  Tannic  acid  oint- 
ment (1  drachm  to  the  ounce  of  ointment)  is  beneficial,  and  the  ointment 
of  galls  combined  with  equal  amount  of  the  ointment  of  stramonium  will 
often  be  found  effectual.  The  ointment  of  the  nitrate  of  mercury  mixed, 
with  seven  parts  of  simple  ointment  is  another  good  application.  Enemas 
of  the  tincture  of  the  chloride  of  iron  (ten  minims  to  the  ounce  of  water), 
and  a  somew'hat  similar  enema  made  of  the  subsulphate  of  iron  are  also 
valuable.  Suppositories  of  glycerin  may  perhaps  be  found  convenient  in 
keeping  the  bowels  open ;  and  at  the  same  time  prove  a  good  application 
for  the  affected  structures. 

When  the  tumors  are  in  a  state  of  inflammation,  at  which  time,  of  course, 
the  symptoms  are  aggravated,  an  enema  of  five  minims  of  the  tincture  of 
opium  and  half  an  ounce  of  starch-water  will  give  great  comfort,  as  will  also 
the  insertion  of  a  one-grain  suppository  of  opium.  Hot  water  fomenta- 
tions should  be  applied  to  the  anus,  and  the  patient  kept  in  bed,  with  the 
bowels  made  slightly  loose  with  laxatives.  If  the  piles  are  protruded  and 
strangulated  they  must,  of  course,  be  pushed  back  into  the  rectum,  even 
if  etherization  and  stretching  of  the  sphincter  are  necessary  for  the  accom- 
plishment of  the  object. 

When  palliative  means  fail  to  give  relief,  when  repeated  attacks  have 
rendered  the  tumor  so  large  that  more  or  less  discomfort  is  constantly 
felt,  and  when  repeated  hemorrhage  shows  a  tendency  to  break  down  the 
patient's  health,  a  radical  operation  is  demanded.  Such  an  operation,  if 
properly  done,  causes  a  permanent  cure.  It  should  not  be  undertaken, 
of  course,  when  the  hemorrhoids  are  due  to  pregnancy,  and  perhaps  not 
when  they  are  secondary  symptoms  resulting  from  stricture  or  malignant 
disease  of  the  rectum.  In  the  last  two  cases  the  primary  disease  should 
be  treated  as  an  initial  step  in  the  management  of  the  case. 

Moderately  severe  cases  of  hemorrhoids  may  at  times  be  cured  by 
simple  dilatation  of  the  sphincter  by  means  of  the  surgeon's  two  thumbs 


()40  DISEASES    OF    THE    RECTUM. 

inserted  into  the  anus  and  then  separated  witli  as  much  force  as  he  can 
bring  to  bear  upon  them.  This  operation  recjuires  the  administration  of 
ether  and  should  be  thoroughly  done.  It  often  results  in  such  change  in 
the  circulation  of  the  hemorrhoidal  vessels  as  to  cure  the  patient's  dis- 
ease. When  the  patient  is  not  able  to  remain  in  bed  for  a  few  days  for 
such  an  operation,  cure  may  be  obtained  by  a  protracted  course  of  treat- 
ment by  means  of  injections  of  carbolic  acid  into  the  tumor.  This 
treatment  requires  a  long  time  for  its  accomplishment,  because  each  indi- 
vidual pile  must  be  treated  separately.  The  length  of  treatment,  there- 
fore, depends  upon  the  number  of  hemorrhoidal  tumors,  each  one  requiring 
from  a  week  to  ten  days  for  a  cure  by  this  means.  A  solution  of  carbolic 
acid  of  the  strength  of  about  thirty  grains  to  a  fluidrachm  of  water,  and 
a  fluidrachm  of  glycerin  should  be  used.  The  hemorrhoidal  tumor  to 
be  operated  upon  is  drawn  down  and  about  four  minims  of  this  carbolic 
solution  injected  into  the  centre  of  the  pile  by  means  of  a  hypodermic 
syringe.  It  is  essential  that  the  fluid  be  placed  in  the  centre  of  the  hem- 
orrhoid, and  not  close  to  the  surface,  since  in  such  an  event  it  is  lial)le  to 
cause  sloughing,  with  subsequent  ulceration. 

Of  all  the  operations  proposed  for  the  radical  cure  of  the  more  severe 
cases  of  hemorrhidal  disease,  the  best  probably  is  excision  and  cauter- 
ization. The  patient's  bowels  should  be  well  emptied  by  a  laxative  given 
the  night  before,  and  a  large  enema  of  soapsuds  given  a  few  hours  before 
the  operation.  He  is  then  placed  in  the  lithotomy  position ;  that  is,  upon 
his  back,  with  his  knees  and  hips  flexed.  The  surgeon,  as  a  preliminary 
step,  should  widely  dilate  the  anus  by  stretching  it  with  all  his  force  by 
means  of  his  two  thumbs,  which  are  inserted  into  the  bowel.  A  portion 
of  the  large  mass  of  hemorrhoidal  tissue  and  prolapsed  mucous  mem- 
brane is  then  drawn  down  with  a  volsella  forceps.  A  clamp,  consisting 
of  two  blades  of  ivory  protected  by  steel  strips  on  the  outer  surface  and 

Fig.  .399. 


Clamp  for  hemorrhoids. 

which  can  be  screwed  firmly  together,  is  then  placed  upon  the  base  of  the 
pile  and  screwed  tightly,  so  as  to  prevent  hemorrhage  when  the  tumor  is 
cut  off  with  a  pair  of  scissors.  The  surgeon  then  cuts  away  the  mass 
protruding  from  the  blades  of  the  clamp,  leaving  about  a  quarter  of  an 
inch  near  the  clamp.  This  stump  is  left  in  order  that  there  may  be  some 
tissue  left  to  sear  with  the  hot  iron,  which  is  now  applied  to  prevent  hem- 
orrhage from  the  vascular  tissues  when  the  clamp  is  removed.  The  cautery 
iron  should  be  heated  to  a  red  heat,  so  as  to  sear  the  tissues  and  occlude 
the  open  mouths  of  the  vessels.  So  soon  as  the  probability  of  hemor- 
rhage is  thus  prevented  the  clamp  is  removed  and  the  shortened  stump 
allowed  to  recede  into  the  rectum.  The  other  tumors  are  successively 
treated  in  the  same  manner  until  all  have  been  excised  and  .seared.  This 
operation  removes  the  hemorrhoidal  tissue,  prevents  hemorrhage,  and  gives 


HEMORRHOIDS.  641 

an  aseptic  surface  which  cannot  readily  become  infected  by  micro-organ- 
isms in  the  bowels  or  upon  the  outer  surface  of  the  anus.  It  is  thorough, 
efficient,  and  a  less  troublesome  operation  than  the  other  usual  methods. 

The  patient  should  have  his  bowels  moved  about  the  fourth  day  by 
means  of  a  mild  laxative,  such  as  castor  oil.  Even  in  severe  cases  the 
patient  need  seldom  remain  in  bed  for  more  than  five  days,  or  in  the  house 
for  more  than  ten  days.  Retention  of  urine  requiring  catheterization  does 
not  often  occur  after  this  operation. 

Some  surgeons  make  an  incision  around  the  internal  margin  of  the 
anus  and  dissect  out  the  hemorrhoidal  tissue,  after  which  the  mucous 
membrane  is  stitched  to  the  integument  covering  the  sphincter.  This 
operation  is  probably  a  little  more  difficult  to  perform  neatly  than  is  the 
operation  just  given,  and  is  scarcely  so  sure,  it  seems  to  me,  to  be  aseptic. 
If  the  operator  has  not  the  hemorrhoidal  clamp  figured  in  the  diagram, 
the  operation  can  be  satisfactorily  performed  by  the  use  of  an  ordinary 
pair  of  pincers  for  the  clamp  and  a  red-hot  poker  in  place  of  the  cautery 
iron  or  Paqueliu  thermo-cautery. 

External  Hem orrhoids. 

Pathology. — The  term  external  hemorrhoids  has,  unfortunately,  been 
applied  to  three  different  conditions  occurring  at  the  verge  of  the  anus 
external  to  the  sphincter.  The  three  forms  have  been  called  thrombotic 
hemorrhoids,  oedematous  hemorrhoids,  and  cutaneous  hemorrhoids. 

A  thrombotic  hemorrhoid  is  a  blood-clot  beneath  the  muco-cutaneous 
covering  at  the  verge  of  the  anus,  due  to  rupture  of  one  of  the  small 
veins,  or  to  inflammation  and  thrombosis  occurring  in  a  subcutaneous 
vein.  While  straining  at  stool  a'  small  tumor  the  size  of  a  pea  may 
appear  from  rupture  of  a  small  vessel,  and  on  examination  show  a  pur- 
plish color  through  the  thin  skin.  On  the  other  hand,  the  clot  may  be 
due  to  inflammation  of  one  of  the  veins  in  this  locality,  the  inflammation 
being  due  to  irritation  arising  secondarily  from  a  small  crack  or  laceration 
in  the  cutaneous  tissue  at  the  verge  of  the  anus. 

The  first  form,  due  to  rupture  of  a  small  vein,  may  cause  some  little 
pain  and  soon  disappear.  If  inflammation  occurs  around  the  blood-clot 
painful  symptoms  arise  and  even  suppuration  may  occur.  The  symptoms 
then  are  similar  to  those  arising  from  the  second  form  of  thrombotic  pile, 
which  begins  as  an  inflammation. 

The  so-called  oedematous  pile  is  simply  an  inflammation,  Avhich  may  be 
quite  severe,  of  the  muco-cutaneous  crevices  and  elevations  which  are 
normally  present  about  the  anus,  due  to  the  normal  puckering  of  the  skin 
in  that  region.  Such  inflammation  gives  rise  to  pain,  a  bearing-down 
sensation,  and  swelling,  and  is  the  condition  usually  present  when  one  of 
the  laity  speaks  of  an  attack  of  piles.  The  condition,  of  course,  is  simply 
one  of  inflammation  of  the  tissue  about  the  anus,  and  is  in  no  sense 
related  to  either  form  of  pile  mentioned,  except  that  it  occupies  the  same 
locality.  The  term  "  piles,"  as  used  by  the  laity,  is  often  also  the  condi- 
tion called  pruritus  of  the  anus,  either  alone  or  associated  with  one  of  the 
forms  of  internal  or  external  hemorrhoids. 

The  third  condition  to  which  the  name  external  pile  has  been 
applied  is  a  hypertrophy  of  the  muco-cutaneous  folds  without  the  anus, 
giving  rise  to  pedunculated  tumors  or  tabs  of  muco-cutaneous  and  cellu- 
lar tissue.     The  hypertrophy  results  from  previous  attacks  of  inflamma- 

41 


642  DISEASES    OF    THE    RECTUM. 

tion  of  tliese  folds,  such  as  descrilied  under  llie  heading  (edematous  heni- 
orrlioids.  These  enhirged  cutaneous  elevations  give  no  trouble  under 
ordinary  circumstances,  but  when  they  become  inflamed  they  cause  great 
discomfort  and  symptoms  similar  to  those  produced  l)y  the  thrombotic 
and  a^dematous  tumors  just  mentioned. 

Tkr.\tment. — It  will  be  seen  that  the  pathology  of  external  hemor- 
rhoidal tumors  is  quite  different  from  the  vascular  condition  called  internal 
hemorrhoids,  and  therefore  it  will  not  surprise  the  reader  to  find  that  they 
are  treated  in  a  different  manner.  The  thrombotic  form  is  best  managed 
bv  incising  the  ])ea-shaped  tumor  and  scraping  out  the  small  clot,  after 
which  the  anus  should  be  bathed  with  an  antiseptic  solution  and  anointed 
with  a  slightly  astringent  ointment.  The  ointment  of  the  oxide  of  zinc, 
with  which  20  grains  of  carbolic  acid  to  the  ounce  have  been  mixed, 
answers  exceedingly  well. 

Gildematous  piles  are  to  be  treated  by  bathing  the  anus  with  warm 
water,  and  applying  a  similar  ointment  of  the  oxide  of  zinc  and  carbolic 
acid,  or  one  consisting  of  about  ten  grains  of  the  yellow  oxide  of  mercury 
ointment  to  an  ounce  of  simple  ointment.  In  both  cases  the  evacuations 
from  the  bowels  should  be  kept  soft,  so  as  to  prevent  pain  at  defecation. 

The  cutaneous  piles  should  be  let  alone  if  they  cause  no  trouble.  Under 
other  circumstances  they  should  be  cut  off  with  a  pair  of  scissors.  They 
should  never  be  ligated  with  a  string  ;  for  while  ligation  is  applicable  to 
internal  hemorrhoids,  although  inferior  to  excision  and  cauterization,  it 
is  not  adapted  to  these  cutaneous  tumors.  If  the  cutaneous  hemorrhoid 
has  a  very  large  base,  it  should  be  trimmed  off  in  such  a  manner  as  to 
leave  a  sort  of  stump,  in  order  that  the  resulting  cicatricial  contraction 
about  the  anus  may  be  less  marked. 

Cutaneous  hemorrhoids  frequently  co-exist  with  internal  hemorrhoids. 
AVhen  such  a  combination  exists,  internal  hemorrhoids  may  be  treated, 
and  the  cutaneous  ones  clipped  away  at  the  same  operation.  It  must  be 
understood  that  a  danger  after  operations  on  internal  hemorrhoids  is  con- 
cealed hemorrhage  into  the  rectum,  which  is  the  reason  for  using  the  clamp 
and  the  cautery  iron.  In  the  external  tumors,  however,  there  is  no  special 
danger  from  hemorrhage,  because  they  are  not  angeiomas ;  and  if  any 
occurs  after  excision,  the  external  position  of  the  bleeding  point  renders 
it  amenable  to  treatment  by  means  of  ligation  or  some  form  of  pressure. 
When  clipping  away  cutaneous  hemorrhoids  the  operation  should  be  con- 
ducted and  the  wounds  treated  antiseptically. 


Rectal  Abscess. 

Pathology. — Abscesses  may  occur  in  the  cutaneous  tissue  about  the 
anus  (marginal)  ;  in  the  ischio-rectal  space,  which  is  the  fossa  between 
the  ischium  and  the  rectal  tube  (ischio-rectal)  ;  in  the  tissue  between  the 
mucous  membrane  and  the  muscular  coat  of  the  bowel  (inter-mural)  ; 
and  in  the  pelvis  surrounding  the  rectal  wall  (peri-rectal).  There  may 
occur  also  a  gangrenous  cellulitis  about  the  rectum,  giving  symptoms  not 
unlike  those  of  peri-rectal  abscess. 

The  predisposing  causes  of  abscess  in  these  special  locations  are  external 
injury,  irritation  or  puncture  of  the  rectal  wall  by  foreign  substances  in- 
troduced into  the  rectum  through  the  anus,  inilammatiou  due  to  small 
portions  of  hardened  feces,  or  indigestible  substances  swallowed  becoming 
impacted  in  the  folds  of  the  mucous  membrane ;  and  breaking  down  of 


ANAL    FISTULE.  613 

tissue  from  want  of  resistance  to  pyogenic  infection.  In  all  cases  of  acute 
abscess  the  presence  of  pyogenic  bacteria  is  a  necessary  causative  factor. 
Tubercular  infection  may  cause  a  chronic,  or  so-called  "  cold  abscess." 

Symptoms. — Marginal  abscesses  are  similar  to  other  superficial  abscesses, 
both  in  symptoms  and  treatment.  Such  abscesses  may  be  mistaken  for 
piles  unless  the  surgeon  makes  an  ocular  examination.  The  ischio-rectal 
abscess,  which  is  the  most  common  form  in  this  i-egion,  appears  as  a  hard 
mass  between  the  anus  and  the  tuberosity  of  the  ischium.  Aching  and 
throbbing,  with  pricking  sensations,  are  felt ;  the  skin  becomes  hard,  red, 
and  brawny,  and  finally  these  symptoms  are  succeeded  by  fluctuation  and 
evidences  of  pointing. 

Inter-mural  abscesses  are  usually  overlooked  until  they  burst  and  dis- 
charge pus  into  the  bowel,  whence  it  is  evacuated.  Peri-rectal  abscesses 
are  often  similarly  overlooked.  The  sensation  of  weight  and  fulness,  and 
the  pelvic  discomfort  associated  with  this  condition,  are  in  such  cases  fre- 
quently attributed  to  other  lesions.  Rigor  occurring  in  the  course  of  such 
symptoms  should  put  the  surgeon  on  his  guard  as  to  the  possibility  of  sup- 
puration taking  place  in  this  region.  The  finger  introduced  in  the  rectum 
may  detect  swelling,  or  a  fluctuating  tumor  in  cases  of  inter-mural  or 
peri-rectal  abscess.  The  latter,  of  course,  is  much  more  dangerous  than 
the  former,  and  may  be  secondary  to  malignant  disease  or  rectal  stricture. 
Such  abscesses  bursting  into  the  peritoneum  would  probably  lead  to  a 
fatal  issue,  unless  the  surgeon  immediately  opened  the  abdomen  and 
washed  out  the  pelvis. 

Treatment. — All  rectal  abscesses  should  be  opened  as  early  as  possi- 
ble, and  if  it  is  thought  that  suppuration  is  about  to  take  place,  an  inci- 
sion, even  before  the  formation  of  pus,  is  justifiable.  In  the  event  of  pus 
not  being  given  an  opportunity  to  discharge  through  an  opening  made  by 
operation,  a  great  deal  of  burrowing  usually  takes  place  before  spontane- 
ous evacuation  occurs,  and,  in  the  ischio-rectal  form,  an  anal  fistule  is  very 
apt  to  remain. 

Inter-mural  abscesses  may  be  evacuated  by  tearing  through  the  mucous 
membrane  with  the  finger-nail,  or  by  puncturing  it  with  a  knife  intro- 
duced through  a  speculum.  The  ischio-rectal  and  the  peri-rectal  forms 
should  be  opened  by  free  incision  made  through  the  skin,  after  which  the 
abscess  cavity  should  be  curetted.  If  the  curetting  can  be  done 
thoroughly,  the  cavity  may  then  be  sewed  up  by  deep  sutures,  with  the 
hope  of  obtaining  immediate  union.  If  there  is  any  doubt  as  to  the  aseptic 
condition  of  the  curetted  cavity,  a  drainage-tube  had  better  be  introduced 
before  the  wound  is  closed.  Rectal  abscess  thus  treated  will  usually  re- 
cover without  the  formation  of  an  anal  fistule. 


Anal  Fistule. 

Pathology. — An  anal  fistule  is  a  communication  between  the  sui-face 
of  the  buttock  and  the  interior  of  the  rectum  by  means  of  a  narrow  pus- 
secreting  track.  It  results  from  an  ischio-rectal  or  a  peri-rectal  abscess 
which  has  not  been  opened  early  enough  to  prevent  the  formation  of  an 
orifice  into  the  bowel  as  well  as  upon  the  surface  of  the  skin.  After  such 
internal  orifice  has  been  established  there  is  difficulty  in  spontaneous 
healing  of  the  pus-secreting  tract,  because  small  particles  of  feces  get  into 
the  fistule  from  the  calibre  of  the  bowel,  and  because  frequent  movements 
of  the  sphincter  muscle  interfere  with  cicatrization. 


644  DISEASES    OF    THE    RECTUM. 

The  usual  form  of  fistule  has,  as  before  stated,  an  opening  upon  the 
skin  and  an  internal  openinu;  within  the  bowel.  This  is  called  complete 
fistule.  Occasionally  the  fistulous  track  runs  from  the  surface  into 
the  cellular  tissue  surrounding  the  rectum,  but  has  no  opening  into  the 
bowel  (incomplete  or  blind  external  fistule).  At  other  tiuics  there  is  an 
opening  from  the  bowel  leading  into  the  abscess  cavity,  or  suppurating 
tract  in  the  tissues  surrounding  the  rectum,  but  with  no  opening  upon 
the  skin  (incomplete  or  blind  internal  fistule).  These  last  two  forms  re- 
(juire  similar  treatment  to  the  complete  anal  fistule,  though  they  vary 
somewhat  in  symptoms.  Incomplete  external  anal  listule  may  be  due  to 
a  wound  received  from  without.     The  incomplete  internal  listule  is  hard 

Fifi.  400. 


Diagram  of  three  forms  of  anal  listule. 
A.  Complete  fistule.     Ji.  Internal  blind  fistule.     ''.  External  blind  fistule. 

to  recognize,  because  there  is  no  external  indication  of  the  tumor,  except 
when  the  cavity  in  the  tissues  around  the  rectum  fills  up  with  pus  and 
makes  a  slight  bulging  of  the  skin.  This  can  be  made  to  disajipear  by 
pressing  ujwn  the  cutaneous  surface  and  forcing  the  accumulated  pus 
through  the  internal  opening  into  the  rectum.  The  diagnosis  in  such 
cases  may  sometimes  be  confirmed  by  feeling  with  the  finger  in  the  rectum 
the  ragged  orifice  through  which  the  communication  between  the  cavity 
and  the  bowel  is  kept  up.  In  complete  anal  fistules  the  rectal  opening  is 
usually  within  an  inch  of  the  anus,  but  the  pus-secreting  pouch  or  pocket 
situated  in  the  ischio-rectal  space  may  extend  to  a  higher  point  than  this 
on  the  outside  of  the  rectum.  This  is  readily  understood,  because  at  the 
time  of  the  formation  of  the  abscess  the  pus  may  have  burrowed  upward 
along  the  rectum  before  the  abscess  pointed  and  finally  evacuated  itself 
into  the  rectum.  In  searching  for  the  internal  orifice  of  an  anal  fistule, 
the  surgeon  should  feel  with  the  finger,  or  look  through  the  speculum  on 
all  sides  of  the  bowel  just  within  the  internal  sphincter.  A  probe  pa.ssed 
into  the  external  opening  may,  unless  carefully  manipulated,  find  its  way 
into  the  top  of  the  j)ouch  alongside  of  the  rectum,  or  it  may  readily  be 
forced  into  the  meshes  of  the  normal  connective  tissue,  instead  of  fol- 
lowing the  fistulous  track  and  entering  the  bowel  by  the  orifice  just 
within  the  anus.  The  internal  opening  is  usually  single,  even  when  the 
buttock  is  riddled  by  sinuses  running  in  all  directions.  The  internal 
orifice  will  usually  be  found  to  be  the  same  for  all  these  sinuses  when 
a  probe  is  successively  passed  into  the  various  cutaneous  openings.  The 
rectal  opening  may  be  upon  the  side  of  the  rectum  furthest  from  the 
external  or  cutaneous  orifice,  because  the  pus  has  burrowed  around  the 
gut.  It  must  be  remembered  that  a  sinus  opening  far  down  the  thigh 
may,  when  opened  up,  be  found  to  lead  to  the  rectum.  On  the  other 
hand,  the  surgeon  should  not  forget  that  a  sinus  in  the  neighborhood 
of  the  anus  may  be  due  to  caries  or  necrosis  of  the  tuberosity  of  the 
ischium  or  of  the  coccyx,  and  have  no  connection  whatever  with  the 


ANAL    FISTULE.  645 

rectum.     Usually,  however,  sinuses  in  the  neighborhood  of  the  anus  will 
be  found,  on  careful  exploration,  to  be  anal  fistules. 

Symptoms. — Anal  fistules,  Avhen  complete,  are  recognized  by  the  dis- 
charge of  gas  and  feces  through  the  abnormal  track,  and  by  the  existence 
of  a  slight  purulent  or  sero-purulent  discharge.  The  external  orifice  wall 
occasionally  become  closed  and  remain  so  for  several  days,  perhaps  for  a 
week  or  two,  when  a  slight  increase  of  pain  and  some  swelling  will  be 
followed  by  a  reopening  of  the  closed  orifice,  the  discharge  of  a  small 
amount  of  pus,  and  subsidence  of  the  active  symptoms.  Quite  a  large 
abscess  will  sometimes  form  as  a  result  of  these  temporary  closures  of 
the  external  orifice,  through  which  drainage  ordinarily  takes  place.  A 
similar  closure  may  occur  in  incomplete  external  fistules,  though  in 
these  there  will  at  no  time  be  escape  of  gas  or  feces.  Incomplete  in- 
ternal fistulas  exhibit  at  times  an  intermittent  discharge  of  pus  into 
the  rectum  and  from  the  anus,  especially  when  pressure  is  made  upon 
the  skin,  as  described  above. 

Treatment. — Injecting  the  anal  fistule  with  stimulating  solutions  is 
usually  unavailing.  An  operation  is  almost  always  necessary  for  a  cure. 
Even  in  cases  of  phthisis  an  operation  should  be  performed  as  on  a 
fistule  in  a  healthy  person,  u,nless  the  phthisical  condition  is  actively 
progressing.  There  is  no  more  risk  to  the  patient  than  in  non-phthisical 
subjects.  Anal  fistule  occurring  in  a  patient  with  tuberculosis  of  the 
lungs  should  be  treated  on  the  same  principles  that  would  guide  the 
surgeon  in  operating  upon  any  other  surgical  condition  in  a  tubercular 
subject.  Fistule  resulting  from  stricture  or  malignant  disease  of  the 
rectum  should  not  be  subjected  to  operation,  unless  it  is  evident  that 
the  primary  disease  can  be  dealt  with,  or  that  the  fistulous  complica- 
tion adds  markedly  to  the  patient's  discomfort. 

During  the  operation  for  anal  fistule  the  patient  is  put  in  the  lith- 
otomy position,  or  in  the  elbow-knee  position.  The  surgeon  then  intro- 
duces the  forefinger  of  his  left  hand  into  the  rectum,  and  feels  for  the 
dimple  or  slight  elevation  which  indicates  the  internal  orifice  of  the 
fistulous  track.  This,  in  most  cases,  is  just  inside  the  internal  sphincter. 
A  grooved  director,  slightly  bent  at  the  point,  is  then  introduced  into 
the  external  orifice  and  along  the  pus-secreting  track  until  it  emerges 
through  the  orifice  in  the  rectum.  Ordinarily,  it  is  possible  for  the 
surgeon  to  bend  the  director  with  the  finger  which  is  in  the  rectum 
until  the  point  of  the  instrument  comes  out  at  the  anus.  A  bistoury 
is  then  carried  along  the  groove  of  the  director  so  as  to  divide  the 
sphincter  muscle  and  all  other  structures  between  the  two  openings. 
Any  other  communicating  fistules  or  sinuses  should  then  be  laid  open 
by  incisions  through  the  skin,  but  no  second  opening  into  the  rectum 
should  be  made.  After  all  the  tracks  have  been  thus  laid  open  and 
exposed  to  view,  it  will  be  seen  that  all  communicate  through  the 
various  ramifications  with  one  rectal  opening.  The  membrane  lining 
all  these  sinuses  must  be  scraped  out  with  a  curette  until  healthy  tissue 
has  been  reached.  They  should  then  be  washed  out  with  corrosive  sub- 
limate solution  (about  1 :  2000),  and  the  walls  brought  together  by  cat- 
gut sutures.  This  method  converts  a  chronic  suppurating  surface  into  a 
healthy  one,  makes,  the  wound  aseptic,  and,  by  division  of  the  sphincter 
muscle,  prevents  muscular  movements  of  the  divided  structures,  thus 
giving  great  assistance  to  the  healing  process.  An  antiseptic  dressing 
should  then  be  applied,  and  movement  of  the  bowels  prevented  for  about 
a  week. 


046  DISEASES    OF    THE    RECTUM. 

The  patient's  intestinal  canal  should,  however,  be  thoroughly  emptied 
by  laxatives  and  enemas  before  the  operation. 

If  it  happens  that  no  internal  orifice  can  be  found  when  the  surgeon 
has  his  finger  in  the  rectum,  and  the  point  of  the  director  has  failed  to 
find  one,  tiie  end  of  that  instrument  may  be  pushed  tlirough  the  mucous 
membrane  at  anv  convenient  point  and  the  sphincter  and  other  structures 
divided  and  treated  as  above.  If  the  orifice,  when  found,  is  very  high  up 
in  the  intestines  it  may  be  well  to  cut  through  the  sphincter  and  other 
structures  with  a  probe-pointed  l)istoury  or  scissors,  since  the  point  of  the 
director  cannot  be  bent  so  as  to  protrude  at  the  anus.  Let  the  operator 
be  careful  not  to  tear  up  the  healthy  cellular  tissue  with  a  small  probe 
point  in  his  search  for  an  internal  orifice,  but  remember  that  in  the  vast 
majority  of  cases  the  rectal  opening  is  not  further  than  one  inch  from 
the  anus.  In  internal  incomplete  fistule  the  internal  orifice  should  be 
found  and  the  tissues,  including  the  sphincter,  divided,  after  making  an 
opening  by  forcing  a  grooved  director  or  probe  against  the  skin  from 
within.  In  no  ca.se  should  the  sphincter  muscle  be  divided  in  more  than 
one  place,  since  such  multiple  division  may  lead  to  fecal  incontinence. 
In  women  the  division  should  not  be  made  through  the  anterior  portion 
uf  the  muscle.  When  it  is  impossible  to  scrape  out  the  fistulous  tracts 
thoroughly  and  approximate  them  with  sutures,  it  becomes  necessary  to 
plug  the  wound  witli  antiseptic  gauze  in  order  to  make  it  granulate  from 
the  bottom  and  prevent  a  recurrence  of  the  fistule. 


Recto-vesical,  Recto-urethral,  and  Recto-vaginal  Fistules. 

A  communication  between  the  rectum  and  the  bladder,  the  urethra,  or 
the  vagina  may  occur  as  a  congenital  malformation. 

Such  fistules,  at  times,  result  from  ulceration,  malignant  disease,  or 
injury.  Whether  congenital  or  acquired,  the  abnormal  communication  is 
recognized  by  the  unnatural  course  which  the  feces  or  urine  take  during 
discharge.  If  the  orifice  is  small  a  small  portion  only  of  these  excretions 
will  pass  through  the  abnormal  channel.  If  the  condition  is  not  due  to 
malignant  disease,  attempts  at  closure  should  be  made  by  cauterization 
with  nitrate  of  silver,  the  actual  cautery,  or  by  plastic  operation.  Judic- 
ious cauterization  and  retention  of  the  patient  in  such  recumbent  position 
as  will  prevent  the  urine  and  feces  from  getting  into  the  abnormal  channel 
w'ill  greatly  aid  the  surgeon's  efforts  at  occluding  the  abnormal  fistulous 
aperture. 

•Sometimes  it  is  well  to  make  temporarily  another  abnormal  opening  in 
order  to  divert  the  urine  and  feces  during  the  closure  of  the  original 
defect.  This  opening  is  usually  placed  in  such  a  position  that  it  can  sub- 
sequently be  easily  treated  by  the  surgeon. 

A  speculum  somewhat  similar  to  Sims's  vaginal  speculum,  if  used  in 
the  rectum,  will  permit  the  surgeon's  manipulations  to  be  carried  on  with 
considerable  ease.  The  plastic  devices  used  for  this  condition  are  similar 
to  those  employed  in  gynecological  practice,  when  abnormal  vaginal  open- 
ings are  to  be  closed. 

AxAL  Fissure. 

Pathology. — Among  the  various  forms  of  ulceration  of  the  anus  an  d 
rectum  is  a  peculiar  ulcer  to  which  the  name  anal  fissure  is  applied.     1 1 


ANAL    FISSURE.  647 

is  SO  different  in  its  symptoms  and  treatment  from  the  other  forms  of 
anal  and  rectal  ulcers  that  it  is  better  to  discuss  it  separately. 

Anal  fissure  is  a  local  disease  occurring  in  patients  who  are  otherwise 
in  good  health.  It  is  in  reality  either  a  small  linear  ulcer  just  within  the 
verge  of  the  anus  involving  the  mucous  membrane  covering  the  sphincter, 
or  a  small  ulcer  not  larger  than  the  little  finger-nail  involving  the  mucous 
membrane  of  the  rectum  just  above  the  sphincter.  Such  ulcers  usually 
occur  at  the  posterior  or  coccygeal  portion  of  the  anus. 

A  peculiarity  of  the  condition  is  the  intense  pain  that  occurs  immedi- 
ately after  defecation,  and  which  is  due  to  spasm  of  the  sphincter  muscle. 
An  anal  fissure  frequently  begins  as  a  small  crack  in  the  mucous  mem- 
brane, due  to  the  evacuation  of  hardened  feces  causing  a  tear  in  the 
tissue  named.  This  fails  to  heal  because  of  the  constant  motion  of  the 
sphincter  muscle ;  or  possibly  because  a  tab  of  hypertrophied  mucous 
membrane  or  a  small  rectal  polypus  coming  in  contact  with  it  prevents 
cicatrization.  At  times  small  and  superficial  eczematous  ulcers  may 
occur  upon  the  outer  aspect  of  the  anus.  These  are  due  to  a  want  of 
cleanliness,  or  to  contact  with  leucorrhojal  discharges.  This  slight  condi- 
tion is  quite  different  from  anal  fissure,  is  unaccomj)anied  by  the  intense 
pain  of  the  latter,  and  is  easily  cured  by  cleanliness  and  the  use  of  oxide 
of  zinc  ointment  or  by  some  similar  astringent  application. 

Symptoms. — The  symptoms  of  anal  fissure  are  remarkable,  because  of 
their  severity,  notwithstanding  the  insignificant  appearance  of  the  lesion. 
The  pain,  which  is  the  chief  symptom,  is  intense  and  smai'ting,  and  occurs 
immediately  after  defecation.  This  pain,  may  last  for  a  few  minutes  or  it 
may  continue  for  many  hours.  It  may  radiate  toward  the  coccyx  and 
sacrum,  and  finally  becomes  a  dull  ache  before  disappearing.  There  is 
then  no  return  of  the  pain  until  defecation  is  repeated ;  after  each  stool, 
however,  the  agonizing  pain  occurs.  Sometimes  a  slight  discharge  of  a 
muco-purulent  character  or  a  slight  bleeding  may  be  a  coincident  symp- 
tom. The  manner  in  which  the  pain  is  reflected  occasionally  causes  the 
patient  to  attribute  the  suffering  to  disease  of  the  bladder  or  the  urethra. 
The  bearing-down  sensation,  or  tenesmus,  accompanying  anal  fissure  is 
sometimes  remarkable.  The  dread  of  intense  pain  after  defecation  causes 
the  patient  to  refrain  from  emptying  the  rectum,  and  chronic  constipation 
therefore  occurs  as  a  secondary  symptom.  As  a  sequence  of  the  difficulty 
in  finally  avoiding  the  hardened  fecal  masses  so  produced,  greater  pain 
and  tenesmus  supervene. 

Spasm  of  the  sphincter  muscle  is  the  occasion  of  the  agonizing  distress, 
and  always  exists  in  true  anal  fissure.  The  elevator  muscles  of  the  anus 
may  also  be  involved  in  the  spasmodic  condition.  In  all  instances  of 
severe  pain  after  stool  anal  fissure  should  be  suspected  and  a  thorough 
examination  at  once  instituted.  The  irritable  condition  of  the  sj^hincter 
may  result  in  such  contraction  of  the  anus  when  an  examination  is 
attempted  that  it  will  be  impossible  to  pass  the  surgeon's  finger  into  the 
rectum  without  etherization.  If  the  presence  of  a  fissure  or  linear  ulcer 
is  not  discovered  by  examination  of  the  external  border  of  the  anus,  the 
patient  should  be  etherized  and  the  lower  portion  of  the  rectum  and  the 
interior  aspect  of  the  anus  thoroughly  explored  by  the  finger  and  specu- 
lum. (Fig.  402.)  The  ulcer  may  be  very  superficial  or  it  may  be  deep 
enough  to  expose  the  muscular  fibres.  As  stated  above  it  is  sometimes 
not  linear,  but  a  small  irregular  ulcerated  surface. 

Treatment.^ — When  the  disease  is  of  recent  date  cure  may  occasion- 
ally be  effected  by  maintaining  a  softened  condition  of  the  feces  by  the 


648 


DISEASES    OF    THE     RECTUM. 


use  of  laxatives ;  by  washing  the  parts  after  each  act  of  defecation  ;  and 
by  sraearinir  the  anus  and  lower  portion  of  the  rectum  with  the  ointment 
of  oxide  of  zinc,  or  an  ointment  containing  the  red  oxide  of  mercury  (gr. 
15  to  the  ounce).  When  this  treatment  fails,  and  it  always  will  fail  in 
the  more  chronic  cases,  operative  procedures  are  recpiired.  The  operation 
is  so  unimjKirtant,  and  the  relief  so  great  and  immediate,  that  it  should 
not  be  postponed.  It  is  ordinarily  sufficient  to  etherize  the  patient  and 
thoroughly  paralyze  the  sphincter  muscle  by  stretching  it  with  the  two 
thuml)s.  This  dilatation  should  be  done  thoroughly  and  with  all  the 
power  which  the  surgeon  can  exert  by  introducing   his  two  thumbs  and 

Fui.  401. 


Rectal  speculum. 

forcibly  separating  them,  usually  in  a  lateral  direction.  Some  of  the 
fibres  of  the  sphincter  muscle  are  probably  ruptured  by  this  manoeuvre. 
Another  method,  which  is  said  to  be  more  effectual  than  dilatation,  is  to 
incise  about  one-third  the  thickness  of  the  sphincter  with  a  bistoury. 
The  incision  is  always  made  through  the  base  of  the  ulcer,  beginning  a 
little  above  its  upper  border  and  terminating  at  the  nuico-cutaneous 
junction  at  the  exterior  of  the  anus.  A  speculum  is  usually  needed  to 
enable  the  surgeon  to  perform  this  operation  dextrously.  One  of  the 
forms  of  ointment  mentioned  for  mild  cases  may  then  be  applied. 

When  simple  dilatation  of  the  anus  has  been  selected  as  a  means  of 
cure,  it  is  well  to  scrape  away  with  the  finger-nail,  or  with  a  curette,  the 
granulations  and  indurated  tissue  forming  the  base  of  the  ulcer.  Any 
small  tab  of  mucous  membrane,  polypoid  growth,  or  small  fissure  compli- 
cating the  condition  should  be  excised  or  incised  at  the  .same  time  that 
the  other  operation  selected  is  performed. 


Ulceration  of  the  Anus  and  Rectum. 

Pathology. — Ulceration  about  the  anus  and  rectum  may  be  syphilitic, 
malignant,  tuberculous,  or  dysenteric;  or  it  maybe  due  to  injury  from 
hardened  feces  or  a  syringe  improperly  used,  or  to  foreign  bodies.  In 
old  people  there  occurs  an  ulceration  which  appears  to  be  due  to  chronic 
venous  congestion,  and  is  similar,  therefore,  in  pathology  to  the  senile 


STRICTURE    OF    THE    RECTUM.  649 

ulceration  which  occasionally  shows  itself  in  the  legs.  It  must  not  be 
forgotten,  however,  that  chancre  may  be  found  at  the  anus.  The  ordi- 
nary form  of  syphilitic  ulcer  belongs  to  the  tertiary  or  to  the  congenital 
stage  of  syphilis. 

Symptoms. — Irregular  diarrhoea,  purulent  discharge,  pain,  tenesmus, 
and  other  symptoms  resembling  dysentery  are  the  clinical  features  of 
rectal  ulceration.  The  discharges  often  consist  of  material  resembling 
yeast,  or  at  times  coffee-grounds,  mixed  with  more  or  less  mucus  and  pus. 
IJlceration  in  the  upper  part  of  the  rectum  is  far  less  painful  than  a 
small  ulcer  at  the  lower  part,  as  has  been  described  in  another  paragraph  ; 
nor  does  great  pain  accompany  the  latter  affection  when  the  ulceration 
at  the  lower  part  of  the  rectum  is  extensive.  Examination  with  the 
speculum  reveals  the  condition  of  the  mucous  membrane  of  the  rectum  ; 
and  digital  examination  conveys  to  the  surgeon's  fingers  the  sensation  of 
rough  irregularities  and  stiffened  rectal  walls  quite  different  from  health. 
There  may  be  irregular  distortion  of  the  tube,  and  even  stricture  may 
occur. 

Treatment. — It  is  essential  in  managing  such  a  condition  to  keep  the 
intestinal  excreta  soft  and  to  use  astringent  and  anodyne  enemas  and 
suppositories.  The  recumbent  position  may  be  valuable  in  severe  cases, 
as  it  prevents  abnormal  congestion  of  the  pelvic  viscera.  Washing  out 
the  rectum  with  large  enemas  of  warm  water  containing  boro-glyceride 
(1  to  30)  and  other  non-poisonous  antiseptics  is  a  valuable  means  of  get- 
ting rid  of  irritating  secretions  in  the  rectum  ;  drying  the  ulcer  and  pow- 
dering it  with  a  mixture  of  oxide  of  zinc  (3  grs.),  mild  chloride  of  mer- 
cury (20  grs.),  and  powdered  starch  (2  drachms)  is  good  treatment.  An 
enema  containing  10  drops  of  the  tincture  of  opium  to  the  ounce  of 
starch-water  will  often  relieve  the  distressing  pain.  In  tuberculous  ulcers 
iodoform  in  powder  or  suppository  is  indicated  ;  10  grains  would  proba- 
bly be  a  sufficient,  as  well  as  a  safe,  amount  in  most  circumstances  to 
introduce  into  the  rectum. 

Syphilitic  cases  will  always  demand  antisyphilitic  remedies  in  addition 
to  or  instead  of  the  tonics  generally  needed  in  ulcerations  here.  When 
great  pain  exists  it  may  be  necessary  to  stretch  or  divide  the  sphincter 
muscle  to  relieve  the  spasm  present.  In  some  extensive  ulcerations  the 
pain  from  the  passage  of  feces  over  the  diseased  surface  is  so  great  that 
lumbar  colotomy  or  excision  of  the  lower  portion  of  the  rectum  is 
demanded.  These  important  operations,  however,  are  not  often  required 
by  the  symptoms.  Scraping  away  the  ulcerated  tissue  with  a  curette,  or 
cauterizing  the  ulcer  with  a  red-hot  iron  or  fuming  nitric  acid,  is  often 
sufficient. 

Stricture  of  the  Rectum. 

Pathology. — Malignant  disease  is  often  the  cause  of  stricture  of  the 
rectum,  but  contractions  of  the  rectum  due  to  fibrous  formations  will  here 
be  alone  considered.  These  contractions  are  due  to  chronic  inflamma- 
tion, or  to  such  prolonged  irritation  of  the  muscular  fibres  in  the  rectal 
wall  as  to  cause  them  to  undergo  a  sort  of  fibroid  degeneration.  The 
coats  of  the  rectum  at  the  seat  of  coarctation  are  thickened  or  welded 
together  either  by  a  new  fibrous  tissue  or  an  increase  of  the  normal 
fibrous  tissue.  Ulceration  of  the  mucous  membrane  is  not  uncommon  in 
the  vicinity  of  the  stricture,  and  dilatation  of  the  tube  naturally  takes 
place  above  the  stricture  from  retention  of  fecal  masses  at  that  point. 


650  DISEASES    OF    THE    RECTUM. 

The  stricture  when  involving  less  than  an  inch  of  the  tube  is  ilenonii- 
nated  an  annular  or  ringed  stricture ;  when  a  greater  length  of  the  intes- 
tine is  contracted  the  term  tubular  stricture  is  applied.  The  former  may 
be  increased  by  further  pathological  changes  and  thereby  be  converted 
into  tlie  latter. 

Inflammation  and  ulceration  of  the  rectum  due  to  operations  upon  this 
organ  or  other  causes,  as  well  as  pelvic  intlauimations  subseipient  to  labor 
may  be  the  exciting  cause  of  fibrous  degeneration  which  results  in  contrac- 
tion of  the  gut, 

Symi'TOMs. — The  first  symptom  of  stricture  of  the  rectum  is  difficulty 
in  defecation,  which  is  usually  considered  by  the  patient  to  be  simply 
functional  constipation.  Finally  the  fecal  masses  discharged  become 
smaller  in  diameter,  resembling,  perhaps,  the  size  and  shape  of  a  lead 
pencil.  At  other  times,  however,  the  extruded  material  consists  of  small 
irregular  masses,  without  definite  shape.  (Occasionally  they  may  even  be 
ribbon-shaped.  Flattened  or  tape-like  feces,  however,  occur  also  from 
irritability  of  the  sphincter  without  there  being  any  stricture  of  the 
rectum.  The  small  nodules  of  feces,  called  scybala,  so  usual  in  constipa- 
tion, must  not  be  mistaken  for  evidence  of  stricture.  A  bearing  down 
sensation  and  a  feeling  of  defecation  being  incomplete  are  marked  feat- 
ures. Diarrhoea,  alternating  with  constipation  and  painful  defecation, 
will,  perhaps,  supervene.  When  ulceration  occurs  as  a  complication  of 
fibrous  stricture,  mucus  and  blood  will  probably  be  mingled  with  the 
feces,  and  the  solid  material  passed  will  be  small  in  amount  and  accom- 
panied with  the  yeasty  or  coffee-ground  discharges  mentioned  as  a  symp- 
tom of  ulceration  of  the  rectum.  The  desire  to  go  to  stool  is  apt  to 
occur  soon  after  the  ingestion  of  food  or  liquid.  The  effort  at  stool  is 
followed  by  little  result,  and  is  soon  succeeded  by  a  repetition  of  the 
tenesmic  sensation,  showing  that  the  rectum  has  not  been  fully  emptied. 

Dyspeptic  symptoms,  such  as  the  accumulation  of  flatus,  become  more 
or  less  prominent.  Abscess  or  fistule  in  the  vicinity  of  the  stricture  may 
cause  the  patient  to  undergo  an  operation  for  its  cure  without  the  sur- 
geon, if  he  be  careless,  discovering  that  the  true  cause  of  this  condition  is 
a  stricture.  Retention  of  feces,  great  emaciation,  excoriation  of  the  anus 
due  to  dischax'ges,  and  intestinal  obstruction  leading  to  peritonitis,  and 
finally  death,  may  result  from  long-continued  fibrous  stricture  of  the 
rectum. 

A  definite  diagnosis  can  only  be  made  by  exploring  the  rectum  care- 
fully with  an  oiled  finger.  If  the  stricture  is  within  three  or  four  inches 
of  the  anus  it  can  be  felt.  There  is  usually  less  than  the  normal  contrac- 
tility of  the  sphincter  and  rectum,  and  below  the  point  of  obstruction 
the  rectum  has  a  tendency  to  be  dilated  like  a  distended  balloon.  This 
is  not  due  to  retained  feces  in  this  part  of  the  gut,  for  none  are  retained 
there.  The  tip  of  the  finger  may  discover  a  sort  of  diaphragm  in  which 
there  is  a  small  opening,  or  it  may  feel  a  funnel-shaped  thickening  of  the 
rectum  leading  up  to  a  small  orifice.  The  introduction  of  a  sound  with 
an  acorn-shaped  head  will  enable  the  surgeon  to  determine  whether  the 
contraction  is  annular  or  tubular. 

If  the  disease  is  situated  beyond  the  reach  of  the  finger  it  is  exceed- 
ingly difficult  to  make  an  accurate  diagnosis,  because  the  rectal  bougie 
used  for  examination  may  become  entangled  in  the  mucous  folds  which 
line  the  rectum  or  be  arrested  by  the  promontory  of  the  sacrum.  It  is 
possible  that  an  examination  made  when  the  patient  is  standing,  or  makes 
a  bearing-down  etibrt,  will  bring  the  strictured  portion  within  reach  of 


STRICTURE    OF    THE    RECTUM.  651 

the  finger.  When  a  diagnosis  of  high  stricture  is  rigidly  demanded  a 
very  small  hand,  well  oiled,  may  be  pushed  into  the  rectum  and  thrust  up 
to  the  sigmoid  flexure.  Acute  obstruction  of  the  intestine  may  supervene, 
when  the  stricture  of  the  rectum  does  not  entirely  occlude  the  calibre  of 
the  organ,  by  undigested  food  becoming  impacted  in  the  narrow  opening.  It 
must  be  remembered  also  that  there  is  a  phantom  stricture  of  the  rectum, 
as  there  exists  a  similar  condition  of  the  cesophagus,  and  that  an  enlarged 
prostate  gland  or  a  displaced  uterus  may  push  its  wall  inward  and  create 
a  condition  resembling  stricture.  A  diagnosis  is  then  made  by  the  nor- 
mal condition  of  the  mucous  membrane  and  by  the  symptoms  indicative 
of  the  other  pathological  conditions. 

Teeatme>'t. — The  feces  in  all  forms  of  rectal  strictures  should  be  kept 
in  a  soft  condition  by  the  use  of  laxatives  and  enemas,  and  an  attempt  be 
made  to  restore  the  calibre  of  the  gut  by  gradual  dilatation.  This  is 
undertaken  by  passing  a  well-oiled  bougie  through  the  contracted  portion 
every  other  day  and  allowing  the  instrument  to  remain  in  position  for  a 
few  minutes,  or  perhaps  an  hour,  if  pain  does  not  contra-indicate  the 
longer  period.  The  bougie  should  be  small,  for  no  bougie  that  requires 
force  should  ever  be  passed  through  a  stricture  of  the  rectum.  Any 
attempt  to  force  a  large  bougie  through  the  diseased  area,  or  to  dilate 
the  stricture  rapidly  with  the  finger  or  bougie,  is  liable  to  cause  inflam- 
mation or  rupture  of  the  intestine.  If  no  pain  of  moment  is  produced 
by  the  small  bougie,  larger  sizes  may  be  successively  substituted  for  the 
smaller  instruments  every  four  or  five  days.  At  the  end  of  six  or  eight 
weeks  a  much  larger  bougie  than  that  originally  used  will  probably  be 
comfortably  received,  and  much  relief  will  be  given  to  the  patient  from 
the  dilatation  thus  effected.  It  is  essential  that  no  active  inflammatory 
conditions  be  induced  by  the  dilatations.  After  the  surgeon  has  given  up 
attendance  upon  the  case  the  patient  should  introduce  the  bougie  for  him- 
self about  twice  a  week.  This  should  be  continued  for  many  months  in 
order  to  prevent  recurrence  of  the  contraction.  In  annular  stricture  this 
method  of  ti-eatment  often  produces  cure,  but  it  is  usually  of  little  avail 
in  the  more  serious  tubular  strictures. 

In  the  event  of  failure  of  gradual  dilatation  in  the  treatment  of  annular 
stricture,  internal  incision  of  the  annular  band  may  be  practised,  provided 
that  the  stricture  is  quite  limited  in  its  extent.  If  the  stricture  is  exten- 
sive in  area,  internal  incision  is  not  free  from  risk,  because  the  contact  of 
the  large  wound  with  pus  and  feces,  in  a  position  where  free  drainage  is 
not  obtainable,  is  liable  to  give  rise  to  serious  inflammation  and  burrow- 
ing of  pus.  When,  however,  a  small  and  shallow  incision  is  made  in  the 
lesser  degrees  of  stricture,  such  untoward  complications  are  not  to  be  ex- 
pected. It  therefore  becomes  necessary  in  the  more  extended  annular 
strictures,  and  in  tubular  strictures,  to  perform  linear  proctotomy,  which 
is  a  complete  division  of  the  rectal  w-all  and  the  tissues  behind  it.  After 
this  operation  granulation  slowly  closes  the  wound,  while  the  calibre  of 
the  gut  is  maintained  by  the  use  of  bougies.  Linear  proctotomy  is  per- 
formed by  introducing  a  long  curved  bistoury  through  the  anus  until  its 
point  is  above  the  stricture.  The  posterior  rectal  wall  is  then  punctured, 
and  the  point  of  the  knife  carried  backward  and  downward  toward  the 
end  of  the  coccyx,  until  its  extremity  makes  its  appearance  through  the 
skin  near  the  coccyx.  An  incision  is  then  made  which  divides  the  stric- 
ture, the  rectal  wall  below,  and  all  structures  between  the  anus  and  the 
cutaneous  opening  made  near  the  coccyx.     The  wound  is  packed  with 


652  DISEASES    OF    THE    RECTUM. 

antiseptic  Ljauze,  and    frequently  ^va^^hed  out  with   anti.septio  solutions. 
Bougieing  should  begin  at  the  end  of  the  first  week. 

Bad  tubular  strictures  are  not  amenable  to  treatment  by  any  of  these 
measures,  though  the  simple  form  of  tubular  stricture  may  sometimes  be 
so  treated.  Temporary  relief  from  pain  and  distress  during  defecation 
through  the  diseased  gut  is,  however,  obtainable  by  lumbar  colotomy, 
which  establishes  an  artificial  anus  in  the  left  loin,  and  permits  the  extru- 
sion of  the  feces  at  that  point.  This  operation  gives  great  relief,  and  is 
not  a^  serious  a  procedure  as  would  at  first  be  supposed.  It  should  not 
be  delayed  until  the  patient  is  exhausted  by  suffering. 

^lALifiNANT  Disease  of  the  Anus  and  RectuiM. 

Pathology. — Cylindrical  epithelioma  is  the  form  of  malignant  dis- 
ease which  nearly  always  occurs  in  the  rectum  and  at  the  anus,  although 
sarcoma  and  scirrhus  occasionally  attack  this  locality.  The  malignant 
affection  usually  assumes  an  infiltrated  form,  though  occasionally  the 
growth  is  a  distinct  tumor,  projecting  into  the  calibre  of  the  rectum,  with 
the  mucous  membrane  over  it  remaining  for  a  longtime  normal.  Finally, 
however,  the  malignant  tissue  breaks  through  the  mucous  covering  and 
fungation  occurs.  The  infiltrated  form  begins  between  the  mucous  mem- 
brane and  the  muscular  coat,  and  ulceration  occurs  quite  early. 

Symptoms. — Malignant  disease  of  the  rectum  may  be  present  for  a  con- 
siderable time  before  the  symptoms  are  conspicuous  ;  then  pain,  bleeding, 
muco-purulent  discharge,  diarrhoea,  and  symptoms  of  stricture  supervene. 
The  clinical  history  of  malignant  disease  of  the  rectal  tube  is,  in  fact, 
very  like  that  of  fibrous  stricture  or  ulceration  in  the  same  locality. 
When  the  anus  alone  is  attacked,  the  symptoms  are  similar  to  rectal  dis- 
ease, but  are  more  patent.  A  diagnosis  between  malignant  disea.se  and 
fibrous  stricture  of  the  rectum  is  sometimes  difficult.  In  the  former  con- 
dition, however,  the  mucous  membrane  between  the  seat  of  disease  and 
the  anus  is  usually  less  ulcerated  than  in  stricture.  The  course  of  malig- 
nant disease  also  is  more  rapid  than  that  of  stricture  of  a  non-malignant 
kind. 

A  finger  introduced  into  the  rectum  can  feel  the  diseased  area  if  it  be 
not  more  than  four  inches  frot»i  the  anus.  Ordinarily  the  nodular  char- 
acter of  the  rectal  wall  is  marked,  although  it  happens  sometimes  that  a 
soft  fungous  mass  is  felt.  This  is  the  case  when  the  disease  occurs  as  a 
tumor  rather  than  as  an  infiltration. 

Villous  tumor  of  the  rectum,  which  is  an  innocent  growth,  is  soft  and 
velvety  to  the  touch,  though  thoroughly  resistant.  In  this  respect  it  differs 
from  the  fungous  form  of  epithelioma,  which  is  not  resistant,  has  a  harsh 
feel,  and  is  surrounded  by  indurated  tissue.  This  subjacent  induration  is 
not  found  in  villous  tumor.  The  discharge  from  villous  tumor  is  a  sticky, 
rather  clear  mucoid  fluid  ;  but  it  is  not  purulent,  and  does  not  have  a  dark 
appearance  like  coffee-grounds.  These  are  characteristics  of  the  discharge 
in  cases  of  rectal  epithelioma. 

Fistulous  tracks  connecting  the  rectum  with  the  bladder,  urethra,  or 
vagina  are  not  uncommon  in  advanced  malignant  disease.  Pressure  of 
the  malignant  growth  upon  the  iliac  veins  may  cause  oedema  of  the  legs. 
Death  occurs  from  exhaustion  or  from  intestinal  obstruction  similar  to 
that  which  takes  place  in  fibrous  strictures.  I  have  in  one  case  known 
the  lower  portion  of  the  rectum  and  the  surrounding  structures  to  be  so 


MALIGNAXT     DISEASE    OF     THE     ANUS    AND     RECTUM.       653 

thoroughly  destroyed  by  malignant  disease  that  the  space  between  the 
buttocks  was  converted  into  au  immense  funnel  shaped  opening  with  the 
apex  directed  upward. 

Treatment. — The  treatment  of  malignant  disease  of  the  rectum  should 
be  directed  to  keeping  the  amount  of  fecal  matter  small,  and  the  bowels 
sufficiently  loose  to  avoid  impaction  of  fecal  masses  above  the  stricture 
or  ulcerated  surface.  To  this  end  food  leaving  small  undigested  residue 
and  mild  laxatives  are  to  be  employed.  A  small  amount  of  opium  is  at 
times  necessary  as  an  anodyne.  The  anus  should  be  kept  free  from  irri- 
tation due  to  contact  with  the  acrid  discharges  by  frequent  bathing  and 
the  use  of  oxide  of  zinc  powder  mixed  with  starch  (twenty  grains  to  the 
ounce),  or  by  some  other  soothing  application  applied  externally.  Warm 
water  enemas  thrown  over  the  seat  of  the  disease  by  means  of  a  small 
rectal  tube,  or  a  catheter  passed  beyond  the  malignant  mass  will  be  of 
service  by  cleansing  the  rectum  and  facilitating  evacuation  of  fecal  matter 
lodged  above  the  diseased  area. 

These  palliative  measures  should  not  be  relied  upon,  however,  when  it 
is  possible  to  remove  the  diseased  tissue  by  excision  of  the  rectum.  This 
operation  is  easy  of  accomplishment  in  suitable  cases,  and  gives  great 
relief  to  the  patient  as  well  as  prolongation  of  life.  Excision  of  the  rectum 
should  not  be  done  unless  the  finger  introduced  at  the  anus  can  reach 
above  the  malignant  growth ;  this  means  that  the  growth  must  be  within 
four  inches  of  the  anus. 

Malignant  disease  of  the  posterior  wall  is  more  amenable  to  operation 
than  that  of  the  anterior  or  lateral  walls,  because  of  the  important  struc- 
tures adjacent  to  and  liable  to  be  involved  in  the  disease  when  the  front 
of  the  tube  is  the  seat  of  infiltration.  It  is  possible  in  women,  however, 
to  separate  the  rectum  from  the  vaginal  mucous  membrane,  even  when 
the  anterior  portion  of  the  rectal  tube  is  diseased.  Ojoeration,  therefore, 
is  more  justifiable  in  women  than  in  men  when  the  morbid  growth  occu- 
pies an  anterior  situation.  In  a  case  otherwise  suitable  for  operation  it 
is  essential  that  the  rectum  be  not  tied  down  to  the  surrounding 
structures  through  malignant  infiltration  outside  the  rectal  wall.  The 
general  health  of  the  patient  should  be  in  fair  condition  before  he  is  sub- 
jected to  the  risks  of  operative  complications.  Numerous  cases  are  upon 
record  in  which  there  has  been  no  return  of  the  disease  for  a  number  of 
years  after  excision  of  the  lower  part  of  the  rectum. 

At  the  time  of  the  operation  the  patient,  whose  bowels  have  been  pre- 
viously thoroughly  emptied,  is  put  in  the  lithotomy  position.  The  sphinc- 
ter and  skin  behind  it  are  divided  by  a  straight  incision  extending  back- 
ward to  the  coccyx.  A  semilunar  cutaneous  incision  is  made  around 
each  side  of  the  anal  sphincter  beginning  at  the  front  of  the  jDosterior 
wound  just  made,  and  terminating  in  the  perineum  in  front  of  the  anus. 
The  finger  is  then  inserted  behind  the  rectum  and  used  to  tear  up  the 
attachments  of  the  rectum  posteriorly  and  laterally.  The  intestine  is 
separated  from  the  vagina  or  urethra  and  bladder  in  front  by  careful 
dissection  with  a  knife,  because  the  finger  would  be  liable  to  do  damage 
if  used  for  that  purpose.  In  men  it  is  well  to  place  a  bougie  in  the 
urethra  and  bladder  in  order  that  the  location  of  these  structures  may 
be  clearly  perceived.  After  the  rectum  has  been  thus  detached  from  the 
surrounding  tissues  to  a  point  above  the  seat  of  disease,  it  is  drawn  down 
and  cut  across  with  scissors  at  some  distance  above  the  disease.  In  this 
manner  the  rectal  tube  and  sphincter  muscle  are  completely  removed. 
After  hemorrhage  has  been  stopped  the  wound  is  packed  with  antiseptic 


G54  DISEASES    OF    THE     RECTUM. 

gauze.  No  attempt  should  be  made  to  draw  down  the  intestine  and  stitch 
it  to  tlie  skin.  Such  a  procedure  interferes  with  draiiiaire  and  is  liable 
to  do  damage  to  the  peritoneum  above.  The  cavity  slowly  tills  up  with 
o-ranulation  tissue  and  a  sort  of  pseudo  mucous  membrane  is  developed 
between  the  lower  end  of  the  intestine  and  the  cutaneous  surface.  The 
patient  regains  control  of  the  contents  of  the  intestine  in  about  two 
months.  After  the  tirst  two  or  three  weeks  it  is  well  to  use  the  bougie 
to  prevent  cicatricical  contraction  causing  stricture. 

In  those  cases  in  which  excision  is  not  justifiable,  left  lumbar  colotoray 
should  be  done,  and  not  delayed  too  long,  since  it  adds  greatly  to  the 
comfort  of  the  patient  and  prolongs  life  even  in  cases  of  great  severity. 

In  malignant  disease  of  the  rectum  without  stricture,  but  where  there 
is  great  jiain  caused  by  passage  of  the  feces  over  the  ulcerated  surface, 
left  lumbar  colotomy  is  the  proper  treatment. 

The  operation  of  colotomy  has  been  discussed  under  Diseases  of  the 
Abdomen. 

NoN-MALKiXAXT    ReCTAL   TuMOKS. 

Pathology. — Fibrous  and  adenoid  tumors  having  a  pedicle  are  at 
times  found  in  the  rectum,  and  are  then  called  rectal  polypi.  Fibroid 
rectal  polvpus  is  developed  beneath  the  mucous  membrane  ;  while  adenoid 
polyi)us  originates  in  the  mucous  membrane  itself,  and  may  have  a  very 
long  pedicle.  Rectal  polypus  is  a  comparatively  rare  disease,  but  is 
more  common  in  children  than  in  adults.  The  tumor  is  apt  to  be  pro- 
truded at  stool,  when  it  may  be  mistaken  for  prolapse  of  the  rectum  or 
for  piles.  The  fact  that  hemorrhage  is  one  of  the  symptoms  of  rectal 
polypus  adds  to  the  liability  of  the  disease  being  mistaken  for  hemor- 
rhoids. Anal  fissure  is  occasionally  corajilicated  with  small  rectal 
polypus. 

Tkratment. — The  sphincter  muscle  of  the  rectum  should  be  dilated, 
and  the  polypoid  tumor  drawn  down  and  twisted  ofl^  with  strong  forceps. 
Twisting  of  the  pedicle  is  judicious  in  order  to  avoid  the  possible  occur- 
rence of  hemorrhage.  If  the  tumor  is  sessile  such  removal  by  torsion 
may  be  impossible,  in  which  case  clamping  and  cauterization,  as  employed 
in  removing  piles,  may  be  used.  If  the  surgeon  prefers,  the  tumor  may 
be  removed  with  scissors  after  transfixion  of  its  base  with  needles  carrying 
catgut  or  silk  ligatures.  The  ligatures  may  be  tied  so  as  to  cut  off  the 
blood  supply  before  excision  is  attempted.  Care  must  be  observed  not 
to  divide  them  when  cutting  away  the  growth. 

Villous  tumor  of  the  rectum  is  an  innocent  growth,  adenoid  in  char- 
acter, but  has  a  less  marked  pedicle  than  a  polypus.  It  does  not  spread 
and  infiltrate  the  tissues  as  does  malignant  disease.  The  growth  secretes 
a  stringy  mucoid  discharge,  and  from  it  small  fragments  frequently  break 
off  and  pass  out  at  the  anus.  When  felt  with  the  finger  it  gives  the  im- 
pression of  a  soft  but  resistant  velvety  tumor,  not  surrounded  by  a  hard- 
ened base  as  is  malignant  disease.  It  may  be  present  for  many  years 
without  causing  much  disturbance,  except  a  sensation  of  fulness  in  the 
rectum,  and  occasional  hemorrhage. 

The  proper  treatment  of  villous  disease  is  dilatation  of  the  sphincter 
and  removal  of  the  growth  by  clamp  and  cautery,  or  by  ligation. 
Curetting  may  be  attempted,  if  precautions  are  taken  to  avoid  subsequent 
hemorrhage  by  packing  the  rectum  thoroughly  with  iodoform  gauze  after 
the  operation. 


CHAPTEE     XXIII. 

DISEASES  AXD  INJURIES  OF  THE  URINARY  ORGANS. 

DISEASES    A^'D    I>"JURIES   OF    THE    KIDNEY. 

Methods  of  Examination. — Diagnosis  of  affections  of  the  kidney 
is  made  by  palpation,  general  symptomatology,  and  by  examination  of 
the  renal  secretion. 

The  general  outine  of  an  enlarged  kidney  can  often  be  ascertained  by 
pressure  upon  the  loin  by  the  extended  hand,  while  the  abdominal  walls 
are  relaxed  and  the  patient  lies  upon  the  abdomen  or  side.  Palpation 
may  also  be  made  through  the  vagina,  rectum,  or  an  exploratory  incision 
in  the  loin  or  anterior  abdominal  wall. 

That  the  product  of  each  kidney  maybe  separately  examined,  catheter- 
ization as  well  as  compression  of  the  ureters  has  been  employed,  but  with 
questionable  success.  Where  compression  is  made  use  of,  the  bladder  is 
well  washed  out,  while  both  ureters  are  compressed  against  the  pelvis. 
Then  one  is  let  go,  and  after  twenty  to  thirty  minutes  the  urine  which  has 
come  through  it  is  drawn  from  the  viscus.  The  bladder  is  now  again 
washed,  and  the  other  ureter  allowed  to  flow  whilst  its  fellow  is  compressed. 

Congenital  Malformations. 

Congenital  malformations  of  the  kidney,  so  far  as  surgery  is  concerned, 
consist  of:  Anomalies  of  size,  blood  supply,  implantation  of  ureter,  and 
situation  in  the  abdomen.  There  may  be  but  one  kidney  present,  or  both 
may  be  fused  together  (horseshoe  kidney,  etc.).  Lobulated  and  multiple 
kidneys  are  unusual.     Cystic  disease  is  frequently  congenital. 

Misplacements. 

Misplacements  of  the  kidney  may  be  congenital  or  acquired.  They 
are  of  unusual  occurrence,  and  most  common  in  women.  One  or  both 
may  be  displaced  ;  the  left  more  frequently  than  the  right.  The  amount 
of  displacement  may  be  inconsiderable,  or  such  as  to  make  diagnosis 
almost  impossible. 

The  organ  may  be  misplaced  and  fixed,  or  misplaced  and  yet  movable  ; 
it  is  generally  hypertrophied,  but  normal  in  structure. 

Simjjle  Ilisjylacejnent. 

In  this  variety  the  gland  is  misplaced  and  fixed  at  some  anomalous 
point  almost  anywhere  in  the  abdomen,  but  usually  between  bladder  and 
rectum  or  uterus,  or  over  the  sacral  promontory. 


iibii    DISEASES    AND    INJURIES    OF    THE     URINARY    ORGANS. 


Movable  and  Floati\<;  Kidnky. 

Here  the  organ  may  be  normally  or  abnormally  situated,  but  is  capable 
of  niakim:  regular  or  more  or  less  erratic  excursive  movements.  Movable 
kidney  diHers  from  floating  ki<lney  in  that  the  former  remains  behind  the 
peritoneum,  and  has  a  more  or  less  limited  up-and-down,  lateral,  or  rotary 
movement  between  that  membrane  and  the  spinal  muscles;  while  the  latter 
has  pushed  through  the  peritoneum,  thereby  securing  a  meso-ne|)hron  and 
an  ahnost  unlimited  range  of  motion.  In  either  case  the  renal  vessels 
become  elongated.  It  is  frequently  impossible  to  differentiate  the  two 
varieties. 

Causes. — The  causes  are  loose  connections  of  capsule,  injuries,  traction 
or  pressure  from  growths,  hypertrophy  or  pregnancy,  distention  of  renal 
pelvis,  and  congenital.  Most  cases,  particularly  of  floating  kidney,  arise 
from  the  latter  cause.  During  motion  of  the  organ  its  vessels  or  ureter 
(pedicle)  may  become  twisted,  and  result  either  in  atrophy  of  the  renal 
tissues  or  distention  of  the  renal  pelvis  by  urine.  Floating  kidney  may 
become  prolapsed  into  hernise. 

Symptoms. — Evidence  of  movement  or  displacement  by  palpation  ; 
dragging  or  acute  pain  in  loin  or  in  the  displaced  organ  ;  sense  of  a  mov- 
ing body  along  spine  or  in  abdomen  ;  pain  caused  by  certain  attitudes  or 
motions,  as  upon  lying  upon  one  side;  increased  frequency  of  micturition  ; 
disturbances  of  bladder,  bowels,  stomach,  or  min  1— even  hypochondriasis 
or  insanity. 

Treatment. — Corsets  and  imprudent  exercise  must  be  avoided.  This, 
with  perhaps  the  wearing  of  some  supporting  mechanical  appliance  or  an 
abdominal  belt,  will  suffice  for  most  cases.  If  the  inconvenience  or  suf- 
fering justify  operation,  nephrorrhaphy  should  next  be  performed.  Should 
this  fail,  or,  in  any  case,  if  the  organ  be  also  diseased,  nephrectomy  may 
be  done  after  it  has  been  ascertained  that  a  second  kidney  exists.  There- 
fore, abdominal  nephrectomy  will  generally  be  more  preferable  than 
lumbar  nephrectomy. 

Hydro-nephrosis. 

Distention  of  the  pelvis  and  calices  of  the  kidney,  resulting  from  back 
pressure  of  urine  due  to  partial  or  complete  mechanical  obstruction  at  a 
lower  point. 

The  obstruction  may  be  situated  anywhere  between  the  renal  pelvis  and 
meatus  urinarius,  but  is  usually  found  in  the  ureter,  and  caused  by  pres- 
sure from  without,  as  by  uterine  fibroids,  etc.,  also  by  impacted  calculi 
and  stenosis,  chronically  over-distended  bladder,  stricture  of  urethra,  or 
phimosis. 

One  or  both  kidneys  may  be  involved,  depending  upon  the  site  and 
nature  of  obstruction. 

The  affection  may  be  (1)  congenital  or  (2)  acquired. 

1.  Obstruction  is  likewise  congenital.  There  is  great  distention — per- 
haps sufficient  to  interfere  Avith  or  prevent  parturition,  and  both  sides  are 
nearly  always  involved. 

2.  Here  distention  follows  injuries  and  other  acquired  obstructions  to 
the  renal  outlet. 

Pathology. — The  pelvis  primarily,  and  calices  secondarily,  become  dis- 
tended and  stretched  by  pressure  of  the  retained  urine.     Finally,  partial 


HYDRO-XEPHROSIS.  657 

or  total  atrophy  of  the  renal  substance  ensues,  the  capsule  becomes  dis- 
tended, and  the  whole  organ  becomes  replaced  by  one  large  cyst.  Hydro- 
nephrotic  cysts  vary  in  size  from  that  of  the  normal  kidney  to  huge  pro- 
portions. The  sac  is  very  prone  to  form  adhesions  to  the  peritoneum  and 
other  surrounding  structures.  Suppuration  may  take  place  within  the 
cyst,  and  give  rise  to  pyo-nephrosis.  Occasionally  they  rupture,  discharg- 
ing their  contents  into  peri-renal  tissues  or  peritoneum.  The  fluid  of 
hydro-nephrotic  cysts  is  urine  of  very  low  specific  gravity,  but  may  in 
part  be  made  up  of  colloid  or  grumous  material. 

Symptoms. — The  symptoms  depend  much  ujDon  the  mode  of  origin. 
Thus,  a  very  gradually  acting  cause  gives  rise  to  no  symptoms  until  a 
tumor  forms  and  signs  of  pressure  or  ulceration  follow.  There  is  always 
percussion  dulness  over  an  increased  area  in  the  loin  ;  the  amount  of 
urine  passed  is  decreased.  When  the  disease  arises  from  acute  cause,  as 
injury  to,  or  torsion  of,  ureter,  impacted  calculus,  etc.,  there  at  once  de- 
velops great  local  and  radiating  pain  and  speedy  formation  of  tumor. 
The  swelling  will  be  irregularly  lobulated,  fluctuating,  flat  on  percussion, 
at  first  occupying  the  loin,  later,  perhaps,  filling  the  entire  abdomen.  The 
colon  is  usually  in  front.  The  tumor  may  disappear  from  time  to  time, 
concomitantly  with  a  large  passage  of  urine  of  very  low  specific  gravity, 
and  perhaps  tinged  with  blood,  owing  to  temporary  giving  way  or  re- 
moval of  the  obstruction.  This  condition  is  termed  intermittent  hydro- 
nephrosis. 

In  either  form,  as  a  rule,  there  is  little  or  no  local  or  systemic  disturb- 
ance, discovery  of  the  tumor  being  the  first  evidence  of  trouble.  Ursemia 
sometimes  supervenes — especially  when  both  kidneys  are  involved.  The 
cyst  may  suppurate  or  rupture  into  the  peritoneal  cavity. 

Diagnosis. — Vaginal  and  rectal  examination  is  of  greatest  value.  The 
contents  of  the  tumor  are  very  similar  to  ascitic  fluid.  Diagnosis  from 
peri-renal  abscess  or  extravasation  is  frequently  impossible,  and  fortu- 
nately is  of  little  consequence,  as  treatment  for  both  is  identical ;  careful 
examination  will  usually  differentiate  hydro-nephrosis  from  ovarian  or 
parovarian  cysts.  Prognosis  depends  upon  whether  the  disease  exists 
upon  one  or  both  sides,  rupture  or  non-rupture  of  the  cyst,  and  upon  the 
treatment  employed. 

Treatment. — Examine  for  and  relieve  obstruction,  if  possible.  Accu- 
mulations of  moderate  size  should  only  be  interfered  with  when  there 
is  great  suffering,  inconvenience,  or  danger  to  life.  Gentle  massage  of 
the  tumor  may  displace  an  obstructing  blood-clot,  etc.,  from  the  ureter, 
and  overcome  the  obstruction. 

Operative  treatment  embi'aces :  1.  Aspiration;  2.  Incision  and  drain- 
age ;  3.  Nephrectomy. 

1.  In  most  cases  tapping  is  purely  palliative,  reaccumulation  taking 
place  in  a  very  short  time.  Repeated  aspirations  will  occasionally  per- 
manently relieve.  2.  Where  such  reaccumulation  ensues,  or  suppuration 
of  the  cyst  takes  place,  the  sac  must  be  freely  exposed  from  the  loin 
or  through  the  abdominal  wall,  incised,  washed  out,  the  edges  of  the  cyst 
wound  sutured  to  the  external  incision,  and  a  large  drain-tube  left  in. 
Usually,  but  not  invariably,  a  permanent  urinary  fistula  persists.  Rup- 
ture of  the  cyst  into  the  abdominal  cavity  demands  immediate  abdomi- 
nal section,  flushing  out  of  the  belly  and  cyst,  and  suture  of  the  rent  in 
the  latter  to  the  parietal  incision.  3.  Nephrectomy  may  be  necessary 
when  foul  discharges  continue  for  a  long  time  to  come  from  the  sinus 

42 


G58     DISEASES    AND    INJURIES    OV    THE    URINARY   ORGANS. 

remaining  after  incision  ;  also  for  annoyances  attending  the  presence  of 
a  persistent  fistula,  and  in  certain  cases  of  cyst  rupture. 

Pyo-nephrosis. 

Pyo-nephrosis  is  usually  but  a  late  stage  of  hydro-nephrosis,  where 
suppuration  within  the  cyst  has  taken  place.  It  may  also  arise  from 
cases  of  simple  pyelitis  complicated  by  obstruction.  Acute  hydro- 
nephrosis is  especially  liable  to  evolve  into  pyo-nephrosis.  Repeated 
tappings,  by  infecting  the  cyst,  frequently  produce  the  same  change ;  or 
infecting  material  may  gain  entrance  through  the  ureter  from  Ijelow. 
Obstructive  calculous  disease  of  kidney  or  ureter  is  the  almost  invariable 
primary  cause. 

Symptoms. — In  pyo-nephrosis  there  is  more  rapid  destruction  of  kid- 
ney substance  than  in  hydro-nephrosis,  as  well  as  great  constitutional  dis- 
turbance and  severe  pain,  which  is  increased  by  pressure.  There  are 
fluctuations  of  temperature,  chills,  and,  when  chronic,  hectic.  Tumor 
usually  cannot  be  felt.  The  sac  is  apt  to  form  extensive  adhesions,  and 
to  rupture  into  perinephritic  tissues,  peritoneum,  bowels,  stomach,  peri- 
cardium, pleura,  or  upon  the  surface;  having  one  or  more  fistulous  open- 
ings. Pus  may  be  present  in  the  urine  continuously  or  intermittently, 
if  the  obstruction  is  not  absolute.  Should  complete  destruction  of  the 
kidney  take  place  the  sac  may  shrink,  its  contents  may  be  absorbed  or 
caseate,  and  a  natural,  though  very  rare,  cure  result. 

Treatment. — The  treatment  is  much  the  same  as  for  hydro-nephrosis. 
Massage  should  be  omitted  if  painful,  and  aspiration  must  not  be  repeated 
if  it  fails  once.  The  peripheral  disease — as  stone  or  stricture — must  be 
removed  if  possible.  Nephrotomy  should  be  resorted  to  early,  and  espe- 
cially if  peri-nephritis  exists;  nephrectomy  is  indicated  for  long-continued 
purulent  discharge  or  where  the  obstruction  is  irremediable  and  per- 
manent. 

Suppurative  Nephritis. 

Inflammation  of  the  kidney  which  has  advanced  to  a  suppurative 
stage. 

One  or  both  organs  may  be  aflected,  but,  when  both,  one  to  a  greater 
extent  than  the  other.  Foci  or  pus  may  develop  in  many  portions  of 
the  kidney  (miliary  abscess),  which  later  may  coalesce  into  one  or  more 
large  abscesses ;  or,  from  other  causes,  one  or  more  large  abscesses  may 
originate  in  any  part  of  the  organ.  A  common  cause  will  often  orig- 
inate either  or  both  varieties.  The  kidney  may  become  a  mere  pus  sac, 
all  renal  tissue  being  destroyed. 

Causes. — ^Miliary  abscesses  result  from  pyelitis,  the  presence  of  para- 
sites, calculi,  foreign  bodies,  decomposed  clots,  cancer,  bladder  or  urethral 
disease,  any  urinary  obstruction,  ingestion  of  irritating  drugs,  as  tupentine, 
carbolic  acid,  cantharides,  etc.,  and  as  result  of  pyaemia  and  septic  fevers. 

Larger  renal  abscesses  result  from  coalescence  of  smaller  ones,  inju- 
ries, septic  emboli,  metastasis  from  blood  or  lower  urinary  apparatus, 
calculi  and  other  foreign  bodies,  and  from  continuity  or  contiguity  of 
suppurative  or  other  disease.  Such  abscesses  may  (rarely)  caseate;  or  be 
absorbed  or  discharged  into  the  ureter,  peri-renal  tissues,  or  elsewhere. 

Symptoms. — The  symptoms  are  generally  indefinite  until  late.     There 


PEEI-NEPHEITIS.  659 

is  sometimes  great  constitutional  disturbance  ("  typhoid  state  "),  but  just 
as  often  no  sign  of  a  suppurative  process.  Chills,  fever,  and  local  pain 
or  swelling,  as  well  as  the  history  of  the  case,  may  furnish  valuable  clues. 
Usually,  no  pus  appears  in  the  urine  unless  the  abscess  should  rupture 
into  the  ureter. 

Treatment. — The  treatment  must  be  directed  to  remove  disease  of 
the  lower  urinary  tract,  and  to  prevent  continued  putrefaction  therein. 
Vigorous  stimulation  and  supporting  constitutional  measures  are  early 
indicated.  Quinine  and  laxatives  should  be  freely  exhibited.  Local 
depletion  should  be  reserved  for  acute  cases.  If  the  accumulation  be- 
come diagnosable  or  self-evident,  it  should  be  promptly  laid  open,  and  the 
sac  washed  out,  freed  of  foreign  bodies,  as  calculi,  if  present,  drained  and 
sutured  to  the  surface. 

In  doubtful  cases  exploratory  incision  down  to  the  kidney  may  be 
employed,  and  an  exploring  needle  then  used  to  locate  the  pus  if  present. 


Peri-nephritis. 

Inflammation  of  the  peri-renal  cellulo-adipose  tissues.  Abscess  is  the 
usual  result.  It  may  occur  at  any  age  from  injury,  but  when  otherwise 
caused  is  mostly  confined  to  adults. 

Causes. — The  causes  may  be  (1)  intra-,  or  (2)  extra-renal. 

1.  Laceration  or  abscess  of  kidney,  ulceration,  pyo-nephrosis,  pyelitis, 
tuberculosis,  or  calculi. 

2.  Here  the  kidney  may  or  may  not  be  involved.  The  usual  extra- 
renal causes  are  :  metastasis  to  peri-renal  tissues,  or  involvement  of  them 
by  continuity  or  contiguity  of  irritative,  inflammatory  or  purulent  pro- 
cesses, as  from  the  pelvis,  peritoneum,  testicle,  along  retro-peritoneal  tissues, 
and  from  the  thorax ;  injuries,  urinary  infiltration,  and  infection  after 
renal  operations. 

Pathology. — A  limited  portion  or  all  of  the  peri-renal  tissues  may 
be  involved.  Or  the  inflammatory  process  may  spread  indefinitely  to 
contiguous  structures,  or  pus  burrow  along  the  fasciae  to  a  great  extent. 
The  kidney  may  remain  entirely  uninvolved,  even  after  the  formation  of 
very  large  abscesses  around  it,  but  usually  the  kidney  is  primarily  in- 
volved, and  the  surrounding  tissues  secondarily  take  on  inflammatory 
action  by  ulcerative  extension  or  through  urinary  extravasation. 

Symptoms  are  often  disguised  and  entirely  overridden  by  those  of  the 
causative  disease.  They  vary  according  to  the  acuteness  or  chronicity  of 
the  process.  When  arising  from  injury,  hasmaturia  is  a  frequent  symptom. 
The  "  typhoid  state  "  often  supervenes  in  chronic  or  subacute  cases.  Pain, 
deeply-seated,  dull,  and  increased  by  pressure  or  motion,  exists,  perhaps 
intermittently,  in  the  loin.  A  sense  of  resistance  and  hardness  is  detected 
deep  in  this  region.  The  corresponding  testicle  may  be  retracted,  and 
bladder  irritation,  with  increased  frequency  of  micturition,  may  be 
present.  Or  all  symptoms  may  be  referred  to  the  hip.  Indeed,  the  con- 
tiguity of  the  psoas  muscle  to  the  seat  of  disease  may  readily  confuse  the 
two  diseases,  especially  when,  as  occasionally  happens,  a  peri- nephritic 
abscess  ruptures  into  the  sheath  of  that  muscle  and  points  in  the  groin 
or  upon  the  thigh. 

When  abscess  has  formed,  fluctuation  may  be  developed  in  the  loin,  but 
usually  not  unless  the  collection  is  quite  large,  when  a  marked  tumor 
with  superficial  oedema  appears  in  the  flank.     If  not  interfered  with,  the 


660    DISEASES    AND    INJURIES    OF    THE    URINARY    ORGANS. 

abscess  will  open  upon  the  abdominal  wall,  through  the  pelvis  upon  the 
buttock,  into  intestines,  peritoneum,  vagina,  bladder,  rectum,  lung,  or 
psoas  sheath.  The  contained  pus  is  often  violently  offensive,  but  may  be 
odorless. 

Diagnosis. — Peri-nephritis  must  be  distinguished,  by  the  above  and 
elsewhere  noted  symptoms,  from  rheumatism,  hip,  spine,  or  kidney  dis- 
ease ;  when  upon  the  right  side,  from  appendicitis  and  perityphlitis  ;  from 
typhoid  fever,  impaction  of  feces,  empyema,  and  ])ulmonary  abscess. 

Treatment. — Under  local  counter-irritation  and  depletion,  hot  fomenta- 
tions and  laxatives,  some  case.s  of  peri-nephritis  will  resolve.  But  so  soon 
as  there  is  reason  to  suspect  the  presence  of  pus,  a  lumbar  incision,  as  for 
nephrotomy,  should  be  made.  If  pus  be  found,  make  the  incision  quite 
free,  explore  the  cavity  and  surface  of  kidney,  or  its  interior  if  opened  up, 
with  the  finger,  to  find  a  stone  or  other  foreign  body  if  present.  If  a  sinus 
only  connects  the  kidney  with  the  abscess,  it  should  be  thoroughly  ex- 
plored by  a  probe  or  finger.  All  sloughs  are  now  curetted  away,  the  cavity 
well  washed  out  with  antiseptic  solution,  and  the  wound  sutured,  leaving 
in  a  very  large  drain-tube.  Urinary  fistula  does  not  usually  form  or 
persist. 

Incision  will  be  followed  by  great  relief,  even  if  made  before  actual 
pus  formation.  It  should  be  free  and  subsequently  well  drained.  If  the 
source  of  trouble  is  found  to  be  a  suppurating  or  tuberculous  kidney,  the 
question  of  immediate  or  subsequent  nephrectomy  should  be  considered. 


Tuberculosis  of  Kidney. 

Tuberculosis  of  the  kidney  exists  in  two  distinct  varieties:  1,  As  part 
of  a  general  miliary  tuberculosis,  having  no  surgical  importance,  and,  2, 
where  the  disease  is  localized  in  the  kidney,  or  therein  exists  in  conjunc- 
tion with  tuberculosis  of  other  portions  of  the  urinary  tract. 

2.  In  adults,  but  one  kidney  will  be  found  involved  in  one-half  of  all 
cases;  in  children,  both  are  affected  more  frequently.  Persons  of  all  ages 
seem  equally  liable  to  the  disease.  Usually,  cheesy  masses  form  in  the 
renal  papillte,  and  extend  deeply  into  the  kidney  substance,  involving 
new  areas  in  all  directions.  These  foci  may  coalesce,  degenerate  into  puri- 
form  material,  and  form  a  cold  (tubercular)  abscess.  The  kidney  sub- 
stance is  more  or  less,  perhaps  entirely,  destroyed.  The  ureter  may  become 
plugged  with  pultaceous  tubercular  material.  A  large  tumor  may  forju, 
but  more  usually  enlargement  cannot  be  made  evident.  When  renal 
tissue  is  entirely  destroyed  the  contents  of  its  capsule  may  shrink  and 
calcify,  or  in  any  case  where  the  pus  remains  fluid  or  increases  in  amount 
the  capsule  may  ulcerate  and  let  it  pass  into  adjacent  tissues  or  organs, 
whence  it  subsequently  makes  its  way  to  the  surface.  Tubercular  nephritis 
may  be  complicated  by  the  presence  of  renal  calculi,  when  the  disease 
becomes  much  more  acute,  rapid,  and  destructive. 

Symptoms. — At  first  there  is  often  unaccountable  physical  depression, 
then  pain  and  tenderness  in  the  loin,  but  the  urine  as  yet  remains  un- 
changed. At  a  later  period  blood,  but  in  trivial  amount,  pus,  tubercle 
bacilli,  and  cheesy  masses  may  appear  in  it,  but  never  tube-casts.  With 
these  ])henomena  great  irritability  of  the  bladder  with  increased  frequency 
of  micturition  develops,  and  constitutes  a  very  significant  symptom. 
Later  still,  rigors,  sweats,  hectic,  and  perhaps  fluctuating  tumor  in  the  loin 
appear,  or,  in  lieu  of  the  latter,  the  quantity  of  pus  in  the  urine  may 


RENAL    CALCULI.  661 

greatly  increase.  On  the  other  hand,  any,  or  almost  all,  symptoms  may 
be  absent  in  not  a  few  cases. 

This  disorder  is  most  liable  to  be  confounded  with  renal  calculus,  but 
may  usually  be  differentiated  therefrom  by  the  degree  of  constitutional 
involvement  in  tuberculosis,  and  by  the  absence  of  bacilli  and  much 
greater  amount  of  blood  in  calculus.  Inflammation  of  the  lower  urinary 
tract  is  common  in  the  former  disease,  rare  in  the  latter. 

If  tuberculosis  attacks  both  kidneys  or  affects  a  wide  exjianse  of  the 
urinary  tract,  death  usually  ensues  in  from  a  few  months  to  several  years. 
If  one  gland  alone  be  affected,  cure  may  result  spontaneously  or  through 
surgical  aid.     General  miliary  tuberculosis  may  occur. 

TREATME^'T. — The  general  condition  of  the  patient  should  receive 
treatment  appropriate  to  tuberculosis  elsewhere.  Locally,  nephrotomy 
and  drainage  or  antiseptic  packing  should  be  employed.  AVhen  early 
undertaken,  this  method  is  satisfactory  in  result,  but  when  operation  is 
performed  after  general  destruction  of  the  organ  or  formation  of  peri- 
nephritic  abscess,  nephrectomy  is  more  advisable  if  the  other  kidney  and 
the  lower  urinary  organs  are  not  .similarly  affected. 

Renal  Calculi. 

Renal  calculi  may  form  at  any  age,  but  are  not  frequent  before  the  fif- 
teenth and  after  the  fiftieth  year.  They  may  be  congenital,  pi'esent  in  one 
or  both  kidneys,  single  or  multiple.  They  vary  in  size  from  a  few  grains 
to  several  ounces  in  weight,  and  in  shape  from  round,  or  round  with 
facets  w^here  they  touch  one  another,  to  an  exact  cast  of  the  pelvis  and 
calices  of  the  organ. 

Causes. — The  causes  are  generally  constitutional :  those  predisposing 
to  deposit  of  uric  acid  or  to  decomposition  of  the  urine.  Bat  inflamma- 
tory disorders  of  any  portion  of  the  urinary  apparatus  with  decomposition 
of  urine  may,  by  extension  to,  or  irritation  of,  the  kidney,  give  origin 
to  them.  Foreign  substances,  as  blood-clots,  tumors,  etc.,  in  the  gland  may 
likewise  cause  deposition  of  urine  salts  and  the  formation  of  a  calculus. 
When  arising  from  constitutional  cause,  both  kidneys  are  commonly  in- 
volved, but  when  from  local  causes  the  disease  is  usually  unilateral. 
Stones  located  in  the  tubular  substance  give  rise  to  severe  symptoms 
even  when  of  minute  size,  while  those  situated  in  the  renal  pelvis  or 
calices  may  be  large,  and  exist  for  a  long  time  without  causing  definite 
symptoms  or  being  suspected. 

Usually  the  nuclei  of  renal  calculi  are  formed  by  salts  precipitated 
from  the  urine  in  retention  cysts,  or  by  decomposition  transmitted  to  the 
pelvis  of  the  gland  through  the  ureter.  These  become  plastered  together 
by  mucus,  blood,  etc.,  and  upon  the  nidus  thus  formed  are  deposited  layer 
after  layer  of  uric  acid  or  salts,  until  a  calculus  of  varying  size  is  pro- 
duced. Stones  may  arise  in  any  portion  of  the  kidney,  but  always  pro- 
duce more  or  less  nephritis  or  pyelitis,  according  to  their  situation.  Ab- 
scess may  originate  around  them.  Those  which  develop  in  the  renal  sub- 
stance form  a  bed  for  themselves  by  pressure  absorption,  and  are  apt  to 
ulcerate  into  the  pelvis  or  a  calyx.  Rarely  they  make  their  w^ay  through 
the  capsule,  escape  into  the  surrounding  tissues,  and  cause  perinephritic 
abscess.  By  dropping  into  the  ureter  they  may  pass  into  the  bladder  or 
become  lodged  in  that  canal,  and  give  rise  to  urinary  obstruction  with 
acute  hydro-nephrosis  and  "  renal  colic."     Should  both  ureters  become 


662     DISEASES    AND    INJURIES    OF    THE    URINARY    ORGANS. 

obstructed,  death  may  ensue  from  uraemia.  From  the  bladder  they  may 
pass  jier  urdhram,  or  remain  and  give  rise  to  vesical  calculus.  Finally, 
a  stone  may  become  completely  encysted  in  the  kidney  and  give  rise  to 
no  further  annoyance. 

Symptoms. — If  no  symptoms  are  present  the  case  has  not  yet  become 
surgical.  But  if  signs  are  present  they  usually  comprise  continuous  or 
intermittent  dull  or  agonizing  pain  in  the  loin,  with  retraction  of  the 
corresponding  testicle,  and  perhaps  referred  pains  in  the  penile  head  or 
shooting  down  the  thighs.  Or  pain  may  be  dull  with  acute  exacerba- 
tions. 

There  is  vesical  irritation,  increased  frequency  of  micturition,  and  per- 
haps spasm;  continuous  or  intermittent  hoeraaturia,  even  pus  in  the  urine 
in  acute  cases  or  where  renal  suppuration  or  pyelitis  has  been  set  up. 
Albumin  may  likewise  be  present  intermittingly  or  continuously  either 
from  kidney  irritation  or  consecutive — perhaps  chronic — nephritis.  The 
posture  of  the  patient  is  such  as  to  relax  and  ease  the  affected  side  and 
to  prevent  jarring  or  motion.  Exercise,  carriage  or  horseback  riding 
cannot  be  tolerated,  or  may  precipitate  an  attack  of  renal  colic.  Pain 
is  increased  also  by  pressure.  Rarely  very  large  stones  can  be  palpated, 
or,  where  there  are  several,  may  be  felt  to  grate  upon  each  other.  Sym- 
pathetic pain  in  the  opposite  kidney  may  simulate  the  presence  of  stone 
there  also,  but  other  symptoms  will  be  absent. 

Constitutional  symptoms  of  grave  character  may  develop  from  kidney 
changes  incident  to  the  presence  of  calculi.  A  history  of  former  attacks 
or  of  having  passed  uric  acid  or  minute  concretions  is  of  great  diagnostic 
value. 

Treatment. — When  it  is  known  or  strongly  suspected  that  renal 
calculus  is  present,  and  the  symptoms  are  distressing  or  urgent  and 
demand  more  than  tentative  treatment,  the  operation  of  nephro-lithotomy 
.should  be  performed.  Even  should  operation  be  undertaken  and  no 
calculus  discovered,  symptoms  are  invariably  more  or  less  relieved  thereby, 
and  there  are  few  risks  involved.  Moreover,  diagnosis  is  thus  established. 
Where  calculus  is  complicated  with  hydro-  or  pyo-nephrosis,  etc.,  the 
indications  are,  if  possible,  even  more  strongly  in  favor  of  operation. 
Nephrectomy  may  be  found  necessary  to  permanently  relieve  certain 
complicated  cases. 

Renal  Colic. 

Renal  colic  occurs  when  a  calculus  enters  the  ureter.  Its  onset  is  gen- 
erally ver}'  sudden  and  unexpected,  and  apt  to  .set  in  after  exertion, 
coughing,  straining,  etc.,  have  displaced  a  calculus  fi'om  its  renal  bed. 
Pain  is  most  intense,  often  causing  nausea,  vomiting,  fainting,  or  collapse. 
It  darts  down  the  lumbar  plexus  into  the  testicle,  penis,  and  thigh.  Chill 
or  convulsions  may  follow.  There  is  great  vesical  irritability,  tenesmus, 
and  desire  to  micturate  frequently.  The  urine  is  blood-tinged,  dimin- 
ished in  quantity,  and  loaded  with  urates.  Copious  perspirations  take 
place.  These  symptoms  continue  unabated  or  intermittently,  while  mus- 
cular action  and  urine  pressure  force  the  stone  along  the  ureter  and 
finally  into  the  bladder,  when  they  cease  like  magic.  From  a  few  mo- 
ments to  as  many  days  may  be  consumed  in  the  making  of  this  transit. 
Successive  stones  may  follow  the  first  at  varying  intervals. 

Treatment. — Anodynes  to  control  or  palliate  pain,  and  even  an  anses- 
thetic  for  the   more  severe  paroxysms,  should  be   freely  administered. 


TUMOES    OF    THE    KIDNEY."  66S 

Local  or  general  application  of  raoist  heat  is  very  grateful.  If  symptoms 
persist  unduly  the  ureter  must  be  cut  down  upon  and  the  stone  extracted. 
The  latter  is  especially  indicated  where  ur^emic  symptoms  ensue  from 
obstruction  of  one  or  both  ureters. 


Eenal  Fistul.^. 

Renal  fistulse  are  passages  other  than  its  normal  outlet  connecting  the 
kidney  with  the  skin  surface  or  other  organs.  These  usually  are  caused 
by  ulcerative,  suppurative,  or  obstructive  disease,  and  as  a  result  of  acci- 
dental or  surgical  wounds  of  the  organ. 

The  sinuses  may  communicate  with  the  rectum,  small  intestine,  stomach, 
vagina,  or  open  upon  the  groin,  thigh,  etc.,  and  may  themselves  become 
blocked  by  concretions  and  originate  obstructive  symptoms.  Pus  usually 
accompanies  the  urinary  discharge.  The  entire  secretion  of  a  kidney,  or 
but  a  very  small  proportion,  may  thus  escape. 

Treatment. — The  cause  which  has  given  rise  to  the  fistula  should  be 
removed  if  possible,  communication  with  the  kidney  made  evident,  and 
a  long  time  allowed  for  the  tract  to  close  spontaneously,  if  it  will,  before 
other  treatment  is  undertaken.  If  no  success  results  from  these  methods, 
stimulating  injections,  applications  of  the  cautery,  or  laying  open  the 
sinus  may  be  tried.  These  also  failing,  and  the  patient's  condition  de- 
manding, nephrectomy  should  be  done. 


Tumors  of  the  Kidney. 

These  may  be  (1)  solid  or  (2)  cystic. 

1.  The  solid  tumors  which  affect  the  kidney  are :  sarcoma,  carcinoma, 
papilloma,  lipoma,  and  rhabdo-myoma.  Carcinoma  is  most  usually  meta- 
static. All  are  prone  to  degenerations.  They  occur  with  equal  frequency 
in  either  sex  and  at  all  ages.  Both  kidneys  are  not  uncommonly  con- 
jointly or  consecutively  involved.  Renal  tumors  mostly  originate  in  the 
peripheral  cortex  and  spread  inwardly.  There  is  little  tendency  to  involve 
neighboring  structures,  or  to  spread  along  lymphatics,  unless  it  be  during 
advanced  stages,  but  great  size  is  frequently  attained. 

Symptoms. — The  symptoms  are  generally  obscure  until  enlargement 
of  the  organ  can  be  made  out.  Cachexia  and  great  loss  of  weight  indi- 
cate a  malignant  tumor.  Pain — perhaps  referred  to  distant  points — may 
or  may  not  be  present.  In  sarcoma,  carcinoma,  or  papilloma  the  urine 
may  contain  blood  or  bits  of  the  growth  which  may  be  recognized  micro- 
scopically. Fever  is  generally  absent.  Varicocele  and  other  pressure 
symptoms  are  often  very  marked. 

Diagnosis. — The  diagnosis  at  any  stage  of  development  is  often  impos- 
sible without  exploratory  operation.  Gro^i;hs  are  diagnosed  from  inflam- 
matory enlargements,  by  absence  of  fever,  also  of  severe  pain,  as  a  rule. 
Renal  tumors  do  not  project  backward,  the  colon  is  always  in  front ;  there 
is  no  line  of  percussion  resonance  between  the  growth  and  spinal  column, 
and  it  is  usually  of  symmetrical  rounded  proportions. 

Treatment. — Benign  growths,  when  recognizable,  require  no  treat- 
ment except  for  pressure  symptoms  or  inconvenience  occasioned  by 
their  size,  when  nephrectomy  may  be  considered.  When  malignant 
tumors  are  diagnosed  and  there  is  fair  reason  to  believe  that  they  are  of 


664    DISEASES    AND    INJURIES    OF    THE    URINARY    ORGANS. 

primary  origin,  limited  to  one  kidney,  and  other  structnres  have  not 
become  likewise  diseased,  nephrectomy  should  be  attempted. 

2.  Cystic  tumors  of  the  kidney  other  than  have  already  been  consid- 
ered, embrace  :  simple  obstruction  or  conglomerate  cysts — usually  limited 
to  one  kidney;  congenital  cystic  disease,  which  is  always  bilateral,  may 
develop  to  enormous  size  before  birth,  in  infancy,  or  even  late  in  life,  and 
in  which  condition  one  renal  gland  is  unable  to  supplement  or  assume 
the  work  of  its  fellow  ;  and  echinococci,  or  hydatid  cysts.  The  latter 
are  rare,  usually  involve  the  left  kidney,  behave  in  a  manner  almost  pre- 
cisely similar  to  hydro-nephrosis  ;  may  attain  huge  size,  entirely  destroy 
the  kidney  and  rupture  or  suppurate  into  contiguous  tissues  or  organs. 

Trkatment. — All  cysts,  when  large  or  inconvenient,  should  be  treated 
by  incision  and  drainage  (nephrotomy)  through  the  loin  or  any  prominent 
fluctuating  point.  This  measure  failing,  nephrectomy  may  be  employed 
in  all  except  those  arising  from  congenital  cystic  disease,  as  in  the  latter 
the  affection  is  invariably  bilateral,  and  nephrectomy  will  certainly  cause 
death  from  uremia. 

Injuries  of  the  Kidney. 

Slight  contusions,  with  or  without  hsematuria  and  swelling  in  loin,  may 
give  rise  to  nephritis  (traumatic  nephritis).  More  severe  contusions  may 
give  rise  to  laceration  of  kidney  substance  or  rupture  of  the  organ. 
Such  injuries  areattended  by  great  shock,  hsematuria,  or  even  severe  or 
fatal  hemorrhage  through  the  ureter,  and  perhaps  effusion  of  blood  and 
urine  into  the  peri-renal  tissues  or  peritoneum.  Peri-nephritic  abscess, 
pyiemia,  suppression  of  urine,  and  uraemia,  also  bladder  trouble  from 
putrefaction  of  clots  remaining  in  it,  may  subsequently  ensue.  Or  the 
ureter  may  become  choked  with  clots,  cause  obstruction,  and  thus  facili- 
tate even  greater  extravasation  of  urine ;  or  it  may  become  obstructed 
permanently  by  contraction  of  cicatrices  or  adhesions. 

Treatment. — Ordinarily  rest,  anodynes,  and  an  ice-bag  to  the  affected 
loin  are  all  that  will  be  required  primarily.  Symptoms  of  inflammation 
call  for  local  depletion  or  counter-irritation  and  warm  poultices  or  fomen- 
tations. Hemorrhage  may  in  addition  be  treated  by  pressure,  as  with  a 
tight  abdominal  binder.  Peri-renal  abscess  or  extravasation  should  be 
treated  by  incision.  Rupture  into  the  peritoneal  cavity  must  be  treated 
by  immediate  abdominal  section  and  perhaps  nephrectomy. 

Open  Wounds  of  the  Kidney. 

Open  wounds  of  the  kidney  are  usually  inflicted  by  knives,  bullets,  or 
splinters.  When  entering  from  behind,  the  peritoneum  may  escape  injury, 
but  when  the  direction  of  the  vulnerating  force  is  from  the  front,  almost 
invariably  that  membrane  is  injured.  The  kidney  may  prolapse  through 
an  extensive  wound. 

Symptoms. — The  symptoms  of  this  class  of  injuries  are  mainly  those 
described  under  Contusions.  Urine  and  hemorrhage  may  come  from  the 
wound.  Shock  is  severe.  Peritonitis  soon  arises  if  the  abdominal  cavity 
is  involved.     Suppurative  processes  in  the  kidney  are  apt  to  follow. 

Treatment. — The  wound  should  be  enlarged,  explored  and  cleansed. 
Hemorrhage  is  best  controlled  by  packingin  gauze  strips.  If  bleeding 
does  not  persist,  suture  the  wound,  leaving  in  a  large  drain-tube  and 
dress  antiseptically.     If  the  kidney  is  hopelessly  crushed  or  hemorrhage 


OPERATIONS    UPON    THE    KIDNEY.  665 

cannot  be  controlled,  nephrectomy  must  be  resorted  to  at  once.  If  the 
peritoneum  is  involved,  abdominal  section,  followed  by  thorough  cleansing 
of  the  abdomen  and  the  leaving  in  of  a  drain-tube  to  the  seat  of  injury 
should  be  performed  without  delay.  When  the  kidney  is  prolapsed 
through  a  wound,  but  not  badly  injured,  it  may  be  cleansed,  returned  to 
proper  position  and  there  retained  by  sutures  or  packing ;  but  if  much 
injured  it  should  be  cut  from  its  pedicle  after  thorough  deligation  and 
removed. 

Operations  upon  the  Kidney. 

Aspiration. 

Aspiration  or  tapping  of  the  kidney  should  be  performed  under  rigorous 
antiseptic  precautions.  The  aspirating  needle  should  be  inserted  into 
any  prominent  fluctuating  portion  of  the  tumor,  but  if  such  does  not  exist 
the  kidney  may  be  entered  by  introducing  the  instrument  in  a  forward 
and  inward  direction  at  a  point  two  and  a  half  inches  posterior  to  the 
center  of  a  vertical  line  drawn  from  the  last  rib  to  the  anterior  superior 
iliac  spine. 

Nephrorrhaphy. 

Nephrorrhaphy  is  the  operation  of  suturing  a  movable  kidney  to  the 
posterior  abdominal  wall.  The  bowels  having  been  well  emptied  by 
laxatives  and  enemata,  the  patient  is  placed  upon  his  unaffected  side 
with  a  pillow  or  padded  block  beneath  the  loin,  that  the  opposite  flank 
may  be  made  prominent  and  the  space  between  the  ribs  and  ilium 
made  as  great  as  possible.  The  affected  kidney  must  also  be  steadied 
by  pressure  upon  the  anterior  abdominal  wall.  The  twelfth  rib  is  now 
located  by  counting  from  above  downwards,  and  a  four  and  a  half  inch 
incision  is  made  parallel  with  it,  but  three-quarters  of  an  inch  lower, 
and  carefully  deepened  until  the  fatty  renal  capsule  is  well  exposed.  If 
the  anterior  border  of  the  quadratus  lumborum  muscle  is  in  the  way  it 
should  be  freely  divided.  Excessive  hemorrhage  can  be  controlled  by 
temporary  firm  packing  with  hot  sponges  or  gauze.  The  capsule  is  now 
well  drawn  out  and  sutured  by  from  eight  to  twelve  strong  chromicized 
catgut  sutures  to  the  deepest  portion  of  the  wound.  The  wound  is  now 
closed  by  deep  sutures,  several  of  which  should  also  pass  through  the 
fibrous  capsule  or  even  tubular  substance  of  the  kidney.  A  large  drain- 
tube  should  be  left  in,  or  if  there  is  continued  hemorrhage  the  Avound 
should  be  packed  and  allowed  to  heal  by  cicatrization,  thereby  securing 
an  even  stronger  anchorage.  Recumbent  posture  must  be  maintained 
for  five  or  six  weeks,  until  all  adhesions  have  become  firm  and  strong, 
and  a  well-fitting  abdominal  belt  worn  for  a  year  or  two  following. 

Nephrotomy. 

Incision  into  any  portion  of  a  kidney.  Incision  is  made  as  in  nephror- 
rhaphy until  peri-renal  fat,  tumor,  cyst,  or  abscess  is  met  with.  The 
fatty  capsule  is  torn  through  between  forceps,  or  the  cyst  or  abscess  cut 
into  at  once.  Bleeding  must  be  controlled  by  temporary  packing  or 
ligatures  as  the  operation  proceeds.  After  the  kidney  has  been  well 
exposed,  and  palpated  or  explored  by  needle,  it  is  cut  into,  if  necessary, 
in   a   longitudinal  direction   in   the   plane   of  the   uriniferous   tubules 


666     DISEASES    AND    INJURIES    OF    THE  URINARY   ORGANS. 

with  a  narrow-hladed  scalpel.  If  the  disease  is  found  to  be  limited  to 
the  renal  pelvis  that  portion  only  should  be  divided,  A  finger  is  then 
introduced  into  the  renal  substance  or  pelvis  and  exploration  made. 
Even  if  no  disease  be  found,  simple  incision  into  the  kidney  is  usually 
followed  by  disappearance  of  all  pain  and  former  symptoms.  Wounds  of 
the  renal  tissue  often  bleed  fiercely,  but  bleeding  is  ea.sily  controllable  and 
soon  ceases  when  packing  is  resorted  to.     When  large  cy.sts  are  incised 

Fig.  402. 


Horizontal  section  of  body  between  second  and  third  lumbar  vertebi*?e  looking  upward. 
Right  side  of  subject  is  at  the  reader's  left  hand.  Relation  of  kidneys  to  peritoneum 
and  muscles  is  shown.     Peritoneuin  indicated  by  dotted  line.     (Lasgk.) 


After  kidney  incision 
for  several  weeks,  or  a 
in   absence   of    urinary 


their  walls  should  be  sutured  to  the  parietal  wound,  which  should  in  turn 

be  drained  and  deeply  sutured  or  packed  and  allowed  to  granulate.    The 

tube  should  go  to  or  even  into  the  renal  incision.     Secondary  hemorrhage 

must  be  treated  by  packing,  ligature  or  cautery 

urine  may  discharge  from  the  external  wound 

permanent   fistula   may   form,    but    is   unusual 

obstruction. 

Nephro-lithotomy. 

Incision  into  and  removal  of  a  calculus  from  the  kidney.  The  pro- 
cedure is  almost  identical  with  nephrotomy.  When  the  kidney  has  been 
well  exposed,  as  above,  it  is  carefully  palpated  by  carrying  the  index- 
finger  over  it  systematically  in  all  directions.  This  failing  to  locate  the 
stone,  an  exploring  needle  may  be  inserted  in  various  directions.  A 
calcareous  vessel  may  impart  the  sensation  of  having  struck  a  calculus. 
When  the  stone  is  located,  incision  is  made  directly  down  upon  it  as 
nearly  as  possible  in  the  plane  of  the  tubules,  and  it  is  removed  by  the 
finger  or  forceps.  But  if  no  stone  can  by  the  above  means  be  located, 
the  kidney  may  be  incised,  and  an  exploring  finger  introduced.  When 
one  calculus  has  been  removed  search  should  be  made  for  others  which 
may  be  present. 

Nephrectomy. 

Removal  of  a  kidney.  The  kidney  may  be  excised  without  interfering 
with  the  peritoneum,  by  the  (1)  lumbar  or  posterior  method,  or  by  the 
(2)  abdominal  or  anterior  method  through  the  peritoneum.  Both  pro- 
cedures have  marked  advantages  and  distinct  fields  in  certain  cases. 

1.  This  method  affords  the  advantage  of  non-interference  with  perito- 
neum and  excellent  drainage,  but  is  attended  by  the  great  disadvantage 


OPERATIONS    UPON    THE    KIDNEY.  667 

of  having  often  to  ligate  the  pedicle  at  great  depth,  and  not  being  able  to 
ascertain  the  condition  of  the  opposite  kidney.  The  principal  accidents 
to  be  feared  are :  tearing  of  the  peritoneum,  colon,  or  vessels  of  the 
pedicle,  or  opening  up  the  pleural  cavity  by  a  too  extensive  or  too  high 
incision. 

It  is  particularly  adapted  for  small  solid  or  cystic  tumors,  inflammatory 
disease,  or  where  operation  is  undertaken  to  relieve  urinary  fistulee,  or  by 
those  unfamiliar  with  abdominal  surgery. 

2.  This  method  permits  examination  of  the  opposite  kidney,  gives  room 
to  deal  with  and  permits  easy  extraction  of  large  growths,  for  which,  and 
floating  kidney,  it  is  chiefly  indicated.  In  the  hands  of  those  skilled  in 
abdominal  work  this  procedure  may  the  more  frequently,  and  for  other 
conditions,  be  employed. 

Lumbar  Nephrectomy. — Incision  is  made  and  the  kidney  exposed  as 
in  nephrotomy.  If  then  more  room  is  required,  a  second  incision  may  be 
carried  vertically  downward  as  far  as  may  be  necessary  from  a  point  about 
one  inch  anterior  to  the  posterior  extremity  of  the  primary  wound.  The 
organ  is  then  rapidly  shelled  from  its  fatty  bed,  and  the  pedicle,  consist- 
ing of  vessels  and  ureter,  isolated.  This  is  most  easy  where  adhesions  do 
not  exist.  Otherwise  they  must  be  carefully  separated  by  the  fingers. 
If  adhesions  are  very  strong,  the  kidney  capsule  must  be  incised  from  end 
to  end,  and  the  renal  substance  shelled  out  in  the  form  of  tumor  and 
pedicle. 

The  organ  is  next  brought  into  the  wound,  or  out  of  it,  but  using  only 
the  slightest  traction  upon  the  pedicle.  The  latter  is  now  isolated  by 
transfixion  with  an  aneurism  needle  armed  with  a  double  extra  strong  silk 
ligature  into  tAVO  portions — one  consisting  of  the  bloodvessels,  the  other 
of  the  ureter — and  each  is  separately  ligated.  A  third  ligature  is  now 
thrown  around  the  entire  stump  at  a  more  peripheral  point  and  firmly 
tied. 

The  pedicle  is  then  grasped  by  forceps  and  the  kidney  cut  away  con- 
siderably above  the  ligatures.  If  the  ureter  is  healthy,  it  may  be  dropped 
into  the  wound  with  the  pedicle ;  otherwise  it  should  be  isolated  and 
sutured  to  the  skin  margin.  If  the  growth  be  very  large,  it  may  some- 
times be  found  preferable  to  place  a  snood  or  rope  ecraseur  about  the 
pedicle  and  cut  away  the  tumor  before  ligation  is  done.  No  consider- 
able traction  must  ever  be  placed  upon  the  pedicle,  as  it  is  apt  to  be  very 
friable,  and  when  torn  gives  rise  to  terrific  hemorrhage.  The  wound 
should  be  closed  and  dressed  as  in  nephrotomy. 

Abdominal  Nephrectomy. — Abdominal  section  is  made,  as  a  rule, 
through  the  linea  semi-lunaris  of  the  affected  side.  Its  situation  and  extent 
will  depend  upon  the  size  and  location  of  the  kidney,  but  usually  its  centre 
will  be  upon  a  level  with  the  umbilicus.  In  certain  unusual  cases  median 
incision  will  prove  more  advantageous.  The  presence  and  condition  of 
the  opposite  kidney  is  then  ascertained  by  a  finger  introduced  through  the 
wound.  If  that  organ  is  absent  or  also  palpably  diseased,  nephrectomy 
should  be  abandoned  and  the  wound  closed.  Otherwise  the  colon,  which 
usually  presents  in  the  wound,  is  pushed  outward  and  back  toward  the 
spine,  and  the  posterior  layer  of  the  meso- colon  is  exposed  covering  the 
kidney.  While  intestines  are  kept  away  with  large  retractors  or  flat 
sponges,  the  meso-colon  is  incised  vertically  four  inches. 

If  the  tumor  be  cystic,  it  is  now  tapped  with  a  large  trocar  and  its  con- 
tents withdrawn.  Otherwise  the  meso-colon  incision  is  extended  suffi- 
ciently to  permit  delivery  of  the  growth.     Two  fingers  or  the  hand  are 


(\Q9,     DISEASES    AND    INJURIES    OF    THE   URINARY   ORGANS. 

now  introduced,  the  kidney  shelled  from  its  bed,  and  a  pedicle  isolated. 
The  tumor  is  now  raised  up  or  delivered  without  tracti(ni  upon  the 
pedicle,  and  the  latter  is  ligated  as  in  the  lumbar  method.  If  the  ureter 
is  extensively  diseased,  it  should  be  isolated  and  sutured  in  the  abilominal 
wound  or  brought  out  through  a  counter-opening  in  the  loin  made  by 
thrusting  the  knife  from  within  outward.  I)rainage  may  be  secured  by 
the  usual  glass  abdominal  drain,  or  by  a  tube  through  the  counter-opening. 
Where  the  latter  is  employed,  the  meso-colon  wound  should  be  sutured,  if 
possible. 

The  Ureter. 

This  canal  is  liable  to  obstruction,  and  to  become  affected  by  extension 
of  disease  from  the  kidney  above  or  bladder  below.  It  is  but  very  rarely 
primarily  involved  by  disease.  Obstruction  of  the  ureter,  as  by  a  de- 
scending calculus,  usually  gives  rise  to  obstructive  symptoms,  renal  colic, 
or  kidney  disease.  Injuries  may  give  rise  to  extravasation  of  urine  or 
result  in  cicatricial  obstruction.  Obstruction  from  impacted  calculus  may 
occasionally  demand  abdominal  section  and  removal  of  the  stone.  Ne- 
phrectomy of  the  corresponding  kidney  may  be  called  for  by  the  same,  or 
when  the  ureter  has  been  ruptured  or  divided,  as  by  a  stab  or  gunshot 
wound. 

Cafheterization  of  the  ureters  has  for  its  object  to  ascertain  whether  the 
canal  is  pervious  or  to  find  out  the  condition  of  the  urinary  secretion 
coming  from  each  kidney.  The  opei'ation  is  only  possible  of  application 
in  the  female.  The  ui'ethra  is  dilated,  a  finger  inserted,  and  a  ureteral 
orifice  located.  A  special  catheter  is  then  passed  along  the  inserted  finger 
as  a  guide  and  into  the  ureter.  When  a  sufficient  amount  of  urine  has 
been  secured  the  instrument  is  withdrawn,  cleansed,  and  then  introduced 
likewise  into  the  other  ureter.  Attempts  to  locate  the  ureteral  outlets, 
and  into  them  insert  the  catheter  by  the  guidance  of  a  finger  in  the 
vagina,  usually  fail. 

The  Bladder. 

Methods  of  ExAMixATrox. — The  usual  method  of  exploring  the 
bladder  is  by  means  of  solid  metal  sounds,  through  which  are  conveyed 
to  the  educated  hand  a  more  or  less  accurate  idea  of  the  condition  and 
solid  contents  of  the  viscus.  To  the  instrument  can  be  attached  a  sound- 
ing board  which  will  amplify  sounds  elicited  from  contact  with  foreign 
bodies  or  calculi  for  class  demonstration. 

Digital  examination  through  the  vagina,  rectum,  or  bimanual  explora- 
tion— a  finger  in  the  rectum  or  vagina,  and  a  hand  upon  the  abdominal 
wall — are  all  useful  methods,  but  must  be  gently  performed,  especially  in 
the  presence  of  calculi  or  foreign  bodies. 

But  best  and  most  accurate  of  all  methods  is  the  electric  cystoscope 
of  Nitze  and  Leiter,  which  affords  a  visual  examination  of  the  entire 
bladder  wall  and  its  contents.  The  male  bladder  may  also  be  explored 
by  means  of  perineal  or  supra-pubic  cystotomy ;  the  female  bladder  by 
dilatation  of  the  urethra  and  digital  examination. 

Congenita  l  Malformations. 

Congenital  malformations  are  unusual.  There  are  several  varieties, 
such  as  entire  absence,  multiple,  or  two-lobed  bladder  with  a  septum 


EXSTROPHY. 


669 


Fig.  40.3. 


between  and  a  ureter  emptying  into  each  division,  exstrophy,  and  per- 
vious or  patent  urachus. 

Exsto'ophy. 

A  congenital  condition  wherein  proper  development  of  the  alantois  is 
interfered  with  during  intra-uterine  life,  and  results  in  failure  of  the 
anterior  walls  of  the  abdomen  and  bladder  to  unite  in  the  median  line. 
Possibly,  portions  of  the  abdominal  or  bladder  wall  may  be  absent.  The 
defect  is  invariably  associated  with  absence  of  the  symphysis  pubis,  and 
in  the  male  with  complete  epispadius.  Males  are  more  frequently  affected 
than  females,  in  the  proportion  of  ten  to  one.  This  condition,  with  its 
associated  deformities,  is  the  one  which  most  commonly  gives  rise  to 
instances  of  mistaken  sex  and  to  cases  of  so-called  hermaphrodism. 

Symptoms. — At  the  site  of  non-union  of  the  lower  abdominal  wall 
a  glossy  red  vascular  prominence  presents,  terminating  below  in  the 
groove  of  a  deformed  or  split  penis,  or,  in  the  female,  in  a  divided  clitoris 
and  labium  minor  on  each  side.  Above,  the  prominence  usually  termi- 
nates at  the  site  of  the  umbilicus,  which  is  absent.  The  recti  muscles  are 
greatly  separated  clear  to  their  ensiform  insertion.  The  symphysis  pubis 
is  absent,  but  the  ends  of  the  pubic  bones  project  or  can  be  felt  about  two 
to  four  inches  separated  on  each  side,  and  are  connected  beneath  the  urethra 
by  a  tough  ligament  made  up  of  the  hypertrophied  sub-urethral  fibres  of 
the  triangular  ligament.  The  penis  is  flattened  or  split,  complete  epispa- 
dius exists,  and  the  scrotum  may  likewise 
be  divided  or  absent. 

The  testicles  are  usually  in  the  scrotum, 
but  may  remain  in  the  abdomen  or  inguinal 
canal.     Hernise  frequently  co-exist. 

There  is  spreading  of  the  pelvis,  conse- 
quent separation  of  the  thighs,  and  a  char- 
acteristic waddling  gait  from  this  cause, 
and  from  bending  forward  to  prevent  fric- 
tion upon  the  exposed  posterior  bladder 
wall.  This  latter  is  usually  covered  wdth 
sensitive  granulations,  which  bleed  upon 
slightest  contact.  The  ureteric  orifices  are 
plainly  visible,  and  perhaps  surrounded 
by  masses  of  granulations.  From  them 
urine  flows  in  intermittent  jets.  Intra- 
abdominal pressure,  as  from  standing, 
straining,  etc.,  makes  the  protruding  mass 
much  more  prominent.  Distressing  eczema 
of  the  surrounding  tissues  results  from  con- 
tinual contact  of  urine. 

Treatment  at  very  best  can  be  but  pal- 
liative, and  is  often  futile.  India-rubber 
urinals  of  special  design  may  be  worn  by  adults  to  protect  the  surfaces 
and  collect  the  urine,  but  cannot  be  applied  to  children,  and  are  never 
fully  satisfactory.  An  attempt  should  be  made  in  certain  cases  to  partially 
or  W'holly  cover-in  the  exposed  surfaces  by  a  plastic  operation.  The  male 
genital  organs  when  involved  cannot  be  rendered  potent. 

There  is  usually  present  everything  to  make  an  operation  difficult  and 
unsuccessful :  the  abdominal  walls  are  very  thin,  hernise  may  exist  on 


Urinal  for  exstrophy. 


670     DISEASES    AND    INJURIES    OF    THE  URINARY   ORGANS. 

each  side,  the  health  is  run  down,  great  eczema  is  present,  and  asepsis 
cannot  be  maintained. 

Oteration. — All  hair  upon  the  jjroposed  flaps  having  been  pre- 
viously destroyed  by  depilation  or  nitric  acid,  the  parts  and  surroundings 
are  made  surgically  clean.  Three  flaps  are  now  outlined.  A  large  one 
is  dissected  from  above  the  exposed  mucous  membrane,  and  a  smaller 
one  from  each  groin.  The  upper  flap  is  now  turned,  skin  surface  down, 
over  the  bladder,  and  its  upper  angles  sutured  with  wire  to  the  lower 


Fir..  404. 


Fig.  405. 


Operation  for  exstrophy  of  bladder.     (Asiihurst.) 


corresponding  angles  of  the  groin  flaps  at  the  base  of  the  penis.  The 
inner  apposed  edges  of  the  groin  flaps  are  now  sutured  together  in  the 
median  line  over  the  raw  surface  of  the  turned-down  abdominal  flap, 
from  a  point  close  to  the  penile  root  upward  as  far  as  they  will  extend. 
The  distal  extremities  of  the  denudation  wounds  are  coapted  with  hare- 
lip pins,  while  the  raw  surfaces  remaining  are  allowed  to  granulate 
and  cicatrize.  (Ireat  care  is  necessary  in  dissecting  the  flaps  not  to 
injure  the  peritoneum,  also  to  handle  them  carefully  without  traction  or 
forceps,  for  fear  of  subsequent  sloughing.  Nor  must  any  great  tension  be 
put  upon  them  in  suturing;  during  which  latter,  and  until  healing  is  com- 
plete, the  shoulders  should  be  kept  elevated  and  the  thighs  flexed,  to 
secure  utmost  relaxation.  By  this  operation,  if  successful,  irritation  is 
relieved,  and  all  urine  is  delivered  at  a  single  dependent  point,  to  which 
a  urinal  may  be  readily  fitted  and  worn.  The  operation  is  attended  with 
considerable  danger. 

In  the  female,  an  extra  large  abdominal  flap  should  be  cut,  and  the 
inguinal  flaps  should  run  down  well  into  the  labise,  so  that  when  all  are 
coapted  the  vagina  is  also  covered  in.  A  large  tube  should  be  placed 
therein  and  frequently  cleansed. 

Pervious  Urachus. 


Pervious  urachus  may  be  partial  or  complete — the  latter  when  it  opens 
externally  at  the  umbilicus.  It  is  often  associated  with  congenital  absence 
or  obstruction  of  the  urethra.     The  canal  may  be  much  dilated. 


CYSTITIS.  671 

The  entire  urinary  secretion  may  pass  from  the  umbilicus,  a  constant 
dribbling  going  on,  or  this  may  take  place,  in  varying  quantity,  only  when 
micturition  is  performed  or  attempted.  The  umbilicus  and  its  surround- 
ings become  eczematous,  and  a  granular  red  vascular  prominence  sur- 
rounds the  urachal  orifice,  through  which  a  probe  may  be  passed,  or 
perhaps  a  catheter  or  finger  carried  into  the  bladder.  Calculi  may  arise 
in  or  be  delivered  from  the  bladder  into  the  urachus  and  be  discharged 
from  the  umbilicus.  Any  eczema  about  the  umbilicus  should  excite  sus- 
picion and  search  for  a  patent  urachus. 

Treatment. — The  treatment  must  first  be  directed  to  removal  of  ob- 
struction causes ;  then  the  edges  of  the  opening  may  be  cleansed,  pared, 
and  deeply  sutured. 

Congenital  vesico-rectal  fistula,  due  to  absence  or  defect  of  the  posterior 
bladder  wall,  is  irremediable,  the  patient  usually  soon  dying  from  intense 
rectal  irritation  and  diarrhoea.  Other  congenital  vesical  fistulse  are 
described  elsewhere. 

Displacements. 

Displacements  of  the  bladder  are  almost  limited  to  females,  excei^t 
where  the  viscus  has  been  drawn  into  the  inguinal  canal  or  scrotum  as  a 
constituent  part  of  a  hernia.  Other  displacements  are :  prolapse  into  the 
vagina  (vaginal  cystocle)  or  through  the  urethra.  The  latter,  which  is 
almost  wholly  confined  to  young  children,  may  be  complete  (inversion) 
or  incomplete.  Complete  prolapse  presents  a  dark-red  mass  constricted 
about  the  base  with  the  ureter  orifices  in  sight.  It  may  be  reduced  by 
continued  gentle  pressure  and  manipulation.  To  cut  ofi"  or  ligate  the 
mass  would  be  a  fatal  error. 

Vaginal  Cystocele. 

Vaginal  cystocele,  of  varying  degree,  is  quite  common  in  women  who 
have  become  relaxed  or  torn  hereabouts  in  childbirth.  It  protrudes,  when 
distended,  into  the  vagina  or  from  the  vulva  as  a  globular,  fluctuating 
tumor  and  may  contain  calculi.  It  may  give  rise  to  serious  diagnostic 
error  during,  or  to  interference  with,  parturition.  However,  its  nature 
can  always  be  determined  by  passing  a  sound. 

Treatment.— Excise  one  or  more  large  oval  areas  of  vaginal  mucous 
membrane  from  the  surface  of  the  cystocele  and  suture  the  edges  together 
from  side  to  side.     Any  perineal  tear  should  be  repaired  at  the  same  time. 

Cystitis. 

Cystitis,  or  inflammation  of  the  bladder,  may  be  acute  or  chronic  and 
involve  one  or  all  of  the  vesical  walls.  In  a  large  majority  of  cases,  how- 
ever, the  mucous  membrane  is  alone  afiected.  Any  degree  of  inflamma- 
tion from  the  mildest  catarrh  to  that  resulting  in  gangrene  may  prevail. 
Cystitis  is  almost  always  symptomatic  of  other  troubles. 

Acute  Cystitis. 

Acute  cystitis  is  less  common  than  chronic,  which  it  may  supervene 
upon  or  give  rise  to,  and  is  most  frequent  in  men.  Usually  it  is  caused 
by  exposure,  injuries,  extension  of  septic  or  inflammatory  affections  from 


672     DISEASES    AND    INJURIES    OF    THE    URINARY   ORGANS. 

the  urethra  (in  gonorrhdea)  or  kidney,  low  fevers,  the  presence  of  foreign 
bodies  or  tumors,  acute  retention  of  urine,  chemical  and  bacterial  changes 
in  the  urine,  ingestion  of  irritating  drugs,  by  operations  upon  the  organ, 
and  by  rough  or  unclean  instrumentation. 

Pathology  of  lesser  degrees  of  acute  cystitis  corresponds  with  that  of 
mucous  membrane  inflammation  elsewhere.  Where  the  ])rocess  is  more 
violent  the  lining  membrane  presents  a  dark  crimson  hue  throughout, 
deepening  to  purple  or  even  black  about  the  neck,  is  ecchymoscd,  and  in 
places  may  be  necrotic  and  the  muscular  layer  exposed.  Hemorrhages 
may  occur  from  bursting  veins  or  separating  sloughs ;  or  perforation  into 
the  surrounding  tissues  or  peritoneal  cavity  take  place.  Peritonitis  may 
arise  without  actual  perforation. 

Symptoms. — Rigors  or  marked  chill  succeeded  by  burning  pain  in  the 
bladder  and  glaus  penis,  dull  pain  in  the  perineum,  increased  frequency 
of  antl  spasmodic  pain  during  micturition,  and  more  or  less  fever,  constitute 
the  ordinary  symptoms  of  acute  cystitis.  Pressure  upon  the  bladder  is 
intolerable.  The  urine  may  be  blood-tinged  throughout  the  attack,  but 
more  usually  is  replaced  soon  by  pus  and  becomes  ammoniacal.  Acute 
retention  is  common. 

If  the  exciting  cause  be  promptly  removed  resolution  usually  at  once 
takes  place.  Otherwise  it  may  terminate  fatally,  or  gradually  subside 
into  the  chronic  variety.  The  more  violent  forms  are  exceedingly  dan- 
gerous. 

Treatment. — The  patient  should  be  given  a  hot  bath  and  be  put  to 
bed.  Leeches  should  be  applied  to  the  perineum  or  hypogastrium  and 
succeeded  by  poultices.  The  cause  must  be  sought  out  and  removed,  if 
possible.  Laxatives  and  mucilaginous  or  alkaline  diluent  drinks,  perhaps 
aconite  by  mouth  and  anodynes  by  rectum,  must  be  exhibited.  If  symp- 
toms continue  the  bladder  should  be  washed  out  once  or  twice  daily,  and, 
all  the.se  failing,  perineal  or  supra-pubic  cystotomy  must  early  be  resorted 
to.     Retention  is  relieved  by  the  catheter  as  often  as  necessary. 

Chronic  Cystitis. 

Chronic  cystitis  usually  results  from  long-continued  vesical  irritation 
or  follows  an  acute  attack.  It  is  an  inseparable  accompaniment  to  many 
disorders  of  the  urinary  tract,  and  is  usually  symptomatic  of  other  dis- 
orders. Causes  are  :  changes  in  the  urine,  presence  of  tumors  or  foreign 
bodies,  retention  of  or  residual  urine,  disease  of  the  kidney,  prostate  or 
urethra,  instrumentation,  injuries,  venereal  excesses.  Stricture  is  the  most 
prolific  cause. 

Pathology'. — The  vesical  mucous  membrane  becomes  swollen,  rugous, 
softened,  and  presents  patches  of  capillary  engorgement  or  ulceration. 
The  epithelium  desquamates  rapidly  ;  mucus  at  first  and  then  pus  is  poured 
out  in  large  quantity.  The  urine  may  be  acid  at  first,  but  soon  becomes 
alkaline  and  putrescent.  Pus  and  mucus,  also  frequently  blood,  are 
prominent  features.  Decomposition  precipitates  the  urinary  salts,  and 
calculi  or  calcareous  deposits  upon  the  bladder  walls  are  of  frequent 
occurrence.  When  the  disease  has  been  of  long  duration  the  muscular 
wall  becomes  either  hypertrophied  and  contracted,  or  its  fasciculi  become 
irregularly  stretched  apart  while  the  mucous  membrane  sinks  into  the 
intervals,  giving  rise  to  the  condition  known  as  sacculated  or  ribbed 
bladder.     These  depressions  or  sacs  may  become  large  and  retain  decom- 


CYSTITIS. 


673 


Fig.  407. 


posed  urine,  act  as  receptacles  for  calculi,  or  perforate  and  give  rise  to 
peritonitis  or  peri-vesical  abscess.  The  ureters  and  kidneys  sooner  or 
later  also  become  involved,  and  add  greatly 
to  the  seriousness  of  the  disease. 

Symptoms. — The  symptoms  are  mainly 
those  of  the  acute  variety,  but  in  milder  de- 
gree. Only  slight  fever  is  ever  present,  but 
the  combination  of  pain  and  other  distress 
rapidly  undermines  the  general  health.  Renal 
implication  makes  a  general  breakdown  even 
more  rapid.  The  urine  is  turbid,  alkaline, 
and  contains  much  mucus  and  pus,  which 
forms  a  tenacious  clot  at  the  bottom  of  the 
retaining  vessel.  The  bladder  wall  in  late 
stages  will  be  found  ribbed  and  sacculated 
by  the  exploring  sound. 


Fig.  40fi. 


Enlarged  prostate  with  ribbed  and  sacculated 
bladder.     (Druitt.) 


Double  or  "  two-way  "  catheter  for 
washing  out  the  bladder. 


Treatment. — The  cause  must  be  found  and  removed.  Rest  in  bed 
is  essential;  no  exposure  of  any  kind  must  be'allowed.  Milk  is  the  best 
diet.  Drugs,  such  as  quinine,  capaiba,  buchu,  oil  of  sandalwood,  salol, 
and  laxatives  are  useful  for  their  general  or  local  effects.  Depletion  by 
leeches  to  the  epigastrium  or  perineum  and  hot  local  applications  are 
both  curative  and  comforting.  If,  with  the  above,  symptonis  do  not  rap- 
idly subside,  the  bladder  should  be  Avashed  out  once  daily,  at  first  with 
simple  hot  water,  but  later  with  antiseptic  solutions  of  gradually  increas- 
ing strength  as  the  organ  becomes  more  tolerant:  such  as  nitrate  of 
silver  (gr.  1  to  oz.  1  of  water),  borax  (gr.  5  to  oz.  1  of  mucilage-water), 
nitric  acid  (n\^  1  to  half-pint  of  water),  and,  especially  where  urinary 
decomposition  is  excessive,  quinine  bisulphate  (gr.  2  to  oz.  1).  An  injec- 
tion of  a  grain  of  morphia  in  two  ounces  of  water  and  allowed  to  remain 
in  the  bladder  wall  give  ease  or  a  good  night's  rest  in  many  cases. 

43 


674     DISEASES    AND    INJUKTES    OF    THE   URINARY   ORGANS 

These  methods  having  failed,  nothiiij^  remains  but  to  perform  perineal 
cystotomy,  which  gives  permanent  drainage  and  rest  to  the  bladder.  In 
women  this  latter  can  be  accomi)lished  by  dilatation  of  the  urethra,  or  by 
making  an  artificial  vesico-vaginal  fistula. 

Tuberculosis  of  the  Bladder. 

Tuberculosis  of  the  bladder  is  not  so  rare  an  affection  as  formerly  wa.s 
thought.  It  occurs  most  frequently  in  males,  and  between  the  twentieth 
and  fiftieth  year.  Generally  it  is  secondary  to  disease  elsewhere ;  when 
primary  the  prospect  is  more  favorable.  There  are  two  favorite  situations 
for  this  disease — namely,  near  the  trigone  and  upon  the  posterior  wall. 
the  former  being  almost  invariably  secondary  to  prostatic  tuberculosis. 

Symptoms. — The  symptoms  resemble  closely  those  of  calculus.  There 
is  usually  great  j)ain,  tenesmus,  and  contraction  of  the  bladder;  blood, 
pus,  and  tubercle  bacilli  in  the  urine.  The  cystoscope  shows  the  mucous 
membrane  at  first  thickened  in  patches  and.  infiltrated  with  gray  miliary 
tubercles.  These  patches  later  break  down,  leaving  deep,  irregularly- 
round  ulcers  with  infiltrated  edges  and  perhaj)s  surrounding  tpdema. 
Karely  these  perforate  ;  should  they  heal,  a  distinct  scar  remains.  When 
the  disease  is  primary  and  can  be  reached  by  appropriate  treatment,  the 
outlook  is  fair;  but  when  otherwise,  is  most  unfavorable. 

Treatment. — When  primary  (never  otherwise)  and  favorably  situated, 
the  disease  may  be  reached  and  thoroughly  curetted  out  after  supra- 
pubic cystotomy  has  been  performed. 

Vesical  Neuroses. 

Neuralgia,  irritability,  and  spasm  of  the  bladder,  while  they  may  very 
rarely  be  pure  neuroses,  yet  usually  can  be  traced  to  causes  just  beginning 
to  originate  cystitis  ;  of  which,  indeed,  they  are  frequent  precursive  .symp- 
toms. On  the  other  hand,  reflex  nervous  phenomena  arising  from  the 
prepuce,  urethra,  kidney,  or  spine,  and  appearing  iis  vesical  affections,  are 
by  no  means  uncommon. 

Paralysis. 

Lack  of  contractile  power  more  or  less  marked  and  prolonged  may  fol- 
low retention  of  urine,  be  reflex  or  hysterical,  or  due  to  serious  brain  or 
spinal  lesions.  Treatment  should  include:  ])revention  of  urinary  reten- 
tion or  decomposition,  and  attempts  to  remove  the  cause  and  restore  the 
lost  power. 

Atrmy. 

Atony  is  the  term  applied  to  slight  degrees  of  lack  of  contractile  force 
in  the  bladder  wall.  It  is  usually  senile  in  origin,  but  may  be  brought 
about  by  disease  at  any  age.  Treatment  is  practically  the  same  as  for 
paralysis. 

Vesical  Fistula. 

Fistulse  are  rare,  except  in  w^omen.  In  men  they  result  from  non-closure 
of  accidental  or  surgical  wounds,  and  from  ulceration  through  the  bladder 
wall.     They  may  terminate  in  intestine  or  upon  the  perineum,  abdominal 


TUMORS  OF  THE  BLADDER.  675 

wall,  or  thigh.  In  women  parturition  furnishes  the  most  fruitful  cause  ; 
here  they  are  most  apt  to  open  into  the  vagina  or  uterus.  Diagnosis  is 
usually  palpable.     Treatment  is  considered  elsewhere. 

Tumors  of  the  Bladder. 

The  primary  tumors  which  occur  in  the  bladder  are,  in  order  of  rela- 
tive frequency  :  papilloma,  carcinoma,  myxoma,  sarcoma,  fibroma,  and 
myoma.  All  have  a  marked  tendency  to  become  pediculated.  Secondary 
tumors  are  exceptional,  unless  by  extension  from  contiguous  parts. 
Dermoid  cysts  of  the  bladder  have  been  described,  but  they  invariably 
find  their  way  into  the  viscus  by  ulceration  from  without. 

Papillomata. 

Papillomata  are  met  with,  as  a  rule,  in  men  after  pubei-ty,  but  any  age 
or  either  sex  may  give  them  origin.  AVhile  usually  siugle  and  sessile, 
yet  the  entire  bladder  wall  may  become  involved.  Urinary  salts  may 
become  deposited  upon  the  growths  and  give  rise  to  a  false  diagnosis  of 
calculus.  The  vesical  floor  about  the  ureteral  openings  is  their  usual 
situation.  In  structure  they  conform  to  the  usual  type  of  papilloid 
growth,  and  are  covered  with  luxuriantly  proliferating  bladder  epithe- 
lium. Those  developing  in  the  aged  are  very  prone  to  carcinomatous 
changes. 

Carcinomata. 

Carcinomata  are  frequent  in  those  of  advanced  years,  and  in  situation 
correspond  with  papilloma.  They  generally  have  a  broad  base  but  may 
likewise  become  pediculated ;  the  surroundings  are  always  more  or  less 
infiltrated. 

Myxomata, 

Myxomata  or  polypoid  tumors  are  almost  limited  to  childhood.  They 
correspond  pathologically  with  nasal  jDolypi ;  are  often  multiple,  form 
with  rapidity,  and  may  prolapse  from  the  female  urethra  or  obstruct 
that  of  the  male. 

Sarcoma,  fibroma,  and  myoma  are  exceptionally  rare  in  this  situation. 

Symptoms. — The  symptoms  of  bladder  tumor  correspond  mainly  with 
those  of  foreign  bodies.  The  first  sign  of  papilloma  and  myxoma  is  hemor- 
rhage. Blood  may  be  suflxised  through  the  urine,  appear  in  clots,  or  be 
passed  almost  pure ;  it  may  be  continuously  present  or  intermittent,  but 
instrumentation  always  brings  on  or  aggravates  the  hemorrhage.  Later, 
pain,  tenesmus,  and  perhaps  cystitis  set  in.  When  the  tumor  is  malignant, 
however,  symptoms  of  vesical  irritation  or  inflammation  precede  hsemat- 
uria.  Portions  of  the  growth  may  pass  with  the  urine,  or  be  removed 
by  instruments  and  perfect  the  diagnosis.  In  benign  tumors  pain  is  a  late, 
usually  not  prominent,  symptom,  while  in  malignant  disease  it  occurs 
early  and  is  very  distressing.  Cachexia  and  advanced  age  also  point  to 
the  more  serious  affection. 

Rectal,  abdominal,  vaginal,  and  direct  digital  examination  through  a 
perineal  wound  made  for  the  purpose  (external  urethrotomy)  are  valu- 


676     DISEASES    AND    INJURIES    OF    THE    URINARY   ORGANS. 

able  aids  to  diagnosi.-*,  but  nothing  can  eciual  the  visual  asi^istance  afforded 
by  the  cystoscope.  Digital  examination  of  the  female  bladder  may  be 
made  through  the  dilated  urethra. 

Pkognosis. — The  outlook  for  cases  of  malignant  disease  is  invariably 
fatal,  but  a  partial  removal  of  the  growth  may  give  comparative  comfort 
and  much  delay  the  fatal  issue.  Happily,  benign  tumors  are  now  avail- 
able for  successful  operations,  and,  while  always  serious,  are  no  longer 
commonly  fatal. 

Vesical  hemorrhage  is  rarely  fatal,  per  se,  but  weakens  the  constitution 
and  mav  give  rise  to  putrefaction  in  the  organ.  Cystitis  is  a  troublesome 
and  dangerous  complication,  as  it  reduces  the  patient  by  increasing  his 
discomfort. 

Treatmknt. — Papillomata  and  other  benign  growths  should  be 
promptly  removed  bj-  supra-pubic  or  perineal  section,  and  gently  tearing 
them  away  with  the  finger-nail,  fingers,  forceps,  curette,  or  knife.  Or,  if 
a  large  pedicle  is  present,  by  an  ecraseur.  Occasionally,  one  may  be 
delivered  from  the  wound  and  ligated  off.  Still  again,  the  cautery,  which 
is  always  useful  to  check  hemorrhage  after  removal,  may  be  employed  for 
their  destruction.  Vinegar  here  is  a  most  excellent  haemostatic.  From 
the  female  bladder  certain  tumors  may,  in  like  manner,  be  extracted 
through  the  dilated  urethra ;  others  by  incision  through  the  anterior 
vaginal  wall  or  by  the  supra-pubic  operation. 

Secondary  or  metastatic  tumors  of  the  bladder  are  invariably  malig- 
nant, hopeless,  and  re<iuire  but  palliative  treatment. 


Vesical  Calculi.     (Stone  in  the  Bladder.) 

Vesical  calculi  are  found  at  all  ages,  but  principally  after  the  fiftieth 
and  between  the  second  and  thirteenth  years.  Stone  may  be  congenital. 
It  is  much  more  common  in  males  than  in  females,  because  of  the  difficulty 
of  escape  for  small  concretions  and  the  much  greater  prevalence  of 
genito-urinary  disorders,  dissipation,  and  exposure  amongst  the  former. 
Negroes,  and  the  people  of  certain  districts,  are  almost  exempt  from  calculi, 
while  in  other  localities,  especially  where  the  water  is  "  hard,"  stone  is  most 
common. 

Cause-s  are:  (1)  predisposing,  and  (2)  exciting. 

1.  Heredity,  drinking-water,  gouty  or  uric  acid  diathesis,  indigestion, 
dissipation. 

2.  Disease  of  any  portion  of  the  urinary  tract,  presence  of  foreign 
bodies,  or  any  cause  producing  irritation  of  the  bladder,  such,  particularly, 
as  retention  or  decomposition  of  urine. 

Construction. — Most  vesical  calculi  are  composed  of  a  nucleus  upon 
which  have  been  deposited  successive  layers  of  urinary  salts,  all  of  which 
may  be  made  evident  by  sawing  the  stone  in  half.  The  nucleus  may  con- 
sist of  inspissated  blood,  pus,  epithelium,  mucus,  an  aggregation  of 
crystals,  or  a  true  foreign  body,  such  as  a  piece  of  catheter,  splinter  of 
bone,  bullet,  etc.  Upon  it  may  be  deposited  layer  upon  layer  of  the  same 
salt,  or  deposits  of  varying  precipitates  may,  from  time  to  time,  according 
to  changing  conditions,  add  to  its  bulk  and  give  rise  to  what  is  called  the 
alter natlnfj  calculus. 

Number. — Stones  are  most  commonly  solitary,  but  two  or  more  are 
frequently  met  with,  and,  rarely,  great  numbers  are  encountered.  Soft 
stones  may  partially  disintegrate  and  become  fractured  by  bladder  con- 


VESICAL    CALCULI.  •  677 

traction  or  by  concussion  against  one  another  when  multiple,  thus  increas- 
ing the  number  present.  The  more  quickly  formed  and  softer  stones  are 
more  apt  to  be  multiple ;  oxalic  and  uric  acid  calculi  are  almost  always 
solitary. 

Proportions. — The  usual  weight  of  bladder-stones  is  from  three  to  six 
drachms;  but  they  may  be  found  ranging  from  that  of  a  grain  or  two  up 
to  many  ounces.  A  stone  weighing  over  four  pounds  has  been  removed 
from  the  human  bladder  post-mortem.  Form  depends  upon  the  position 
of  origin  and  detention  ;  the  stone  may  correspond  in  shape  with  the  pelvis 
of  the  kidney,  with  that  of  a  saccule  or  other  portion  of  the  bladder,  but 
more  especially  with  that  of  the  nucleus.  The  average  calculus  is  flat- 
tened, oval,  or  round,  and  may  be  smooth,  granular,  or  roughly  tubercu- 
lated.  Multiple  stones  are  apt  to  be  flat,  irregular,  and  to  be  faceted  at 
points  of  mutual  contact. 

Consistence  depends  upon  the  composition.  Those  composed  of 
oxalate  of  calcium  or  uric  acid  are  excessively  hard,  while  phosphatic 
stones  vary  from  the  firmness  of  soft  brick  to  that  of  dried  clay. 

Varieties. — The  usual  types  of  vesical  calculi,  in  order  of  relative 
frequency,  are:  (1)  uric  acid,  (2)  oxalate  of  calcium,  and  (3)  phosphatic. 
These  ingredients  may  be  almost  pure,  or  intermingled  in  various  propor- 
tions or  in  alternating  layers. 

1.  This  variety  is  chiefly  limited  to  youth  and  middle  age  ;  almost 
always  descends  from  the  kidney,  and  constitutes  the  nucleus  of  most 
other  varieties.  They  are  of  slow  growth,  moderate  proportions,  smooth, 
regular  surface,  dark-brown  color,  and  develop  in  acid  urine. 

2.  (Mulberry  calculus.)  Are  more  slow  in  development,  and  harder, 
also  rough  and  irritating.     They  chiefly  appear  during  middle  age. 

3.  Of  this  type  there  are  three  varieties :  (a)  phosphate  of  calcium 
(earthy  phosphates)  ;  (b)  ammonio-magnesium  phosphate  (triple  phos- 
phates), and  (e)  phosphates  of  calcium,  ammonium  and  magnesium 
in  va-rying  combination  or  mixture  (mixed  or  fusible  phosphates). 
Varieties  a  and  b  are  unusual ;  c  is  the  common  representative  of  the 
phosphatic  group.  They  are  large,  irregular,  soft,  white,  generally  have 
a  nucleus  of  harder  calculus  or  foreign  body,  and  originate  in  alkaline 
urine,  usually  during  later  life. 

Other  possible  but  very  rare  varieties  of  stone  are  composed  of  cystic 
oxide  (cystine),  xanthic  oxide,  and  carbonate  of  calcium  or  magnesium. 
Certain  organic  substances  by  inspissation  and  concretion  sometimes  form 
foreign  bodies  in  the  bladder  which,  to  all  intents  and  purposes,  resemble 
true  calculi.     These  may  be  fibrous,  sanguinous,  or  urostealithic. 

Progress. — If  stones  are  not  promptly  removed — perhaps  in  any  case 
— cystitis  and  involvement  of  the  kidneys  may  result.  The  possibility  of 
such  changes  being  present  must  be  borne  in  mind  when  operative  inter- 
ference is  contemplated.  Stones,  if  neglected,  may  ulcerate  through  the 
vesical  wall  into  the  perineum,  rectum,  or  vagina,  or  by  their  presence  in 
the  bladder  impede  or  prevent  childbirth.  Small  calculi  not  infrequently 
(especially  in  the  female)  are  passed  per  urethram. 

Symptoms  of  vesical  calculus  are  chiefly  those  of  the  inflammatory  and 
tubercular  affections  of  the  oi'gan  which  have  already  been  described. 

There  is  the  pain  of  cystitis,  but  perhaps  only  present  at  the  end  of 
micturition,  when  the  stone  is  forced  upon  the  sensitive  trigone  or  neck  ; 
it  is,  in  fact,  referred  to  the  end  of  the  penis,  or  elsewhere,  as  a  rule,  and, 
in  children,  the  prepuce  may  become  very  long  and  redundant  from  con- 
stant pulling  to  relieve  the  pain  there  felt. 


678     DISEASES    AND    INJUEIES    OF    THE  URINARY   ORGANS. 

Often  it  is  more  easy  for  the  patient  to  pass  water  in  certain  positions, 
as  upon  the  back,  side,  or  helly.  Pain  is  least  at  ni«,'ht,  and  when  tlie 
person  is  quiet;  jolting  and  exercise  greatly  aggravate  symi)tonis. 

Frequent  irresistible  desire  to  micturate  is  an  early  and  prominent 
symptom.  The  act  may  be  suddenly  cut  short  by  the  stone  falling  against 
oV  into  the  vesical  outlet.  Blood  is  passed  in  greater  or  less  degree,  con- 
tinuously or  intermittently.  Priapism  and  incontinence  are  common  in 
children.  Often  there  is  agonizing  tenesmus  of  the  bladder  and  rectum 
at  the  end  of  micturition,  when  the  stone  is  grasped  by  the  bladder  wall. 
The  urine  corresponds  to  that  passed  during  cystitis,  but  with  the  presence 
of  a  greater  proportion  of  blood,  as  a  rule.  Normal  urine,  and  entire 
absence  of  symptoms,  are  not  absolutely  incompatible  with  the  presence 
of  even  moderate-sized  stones. 

Dia<;nosis. — A  history  of  inheritance,  gouty  diathesis,  previous  calculus, 
or  of  renal  colic,  may  render  diagnosis  more  easy,  but  scarcely  any  symptom 
or  group  of  sym{)toms  is  pathognomonic.  Stone  may  complicate  other 
diseases,  while  almost  all  urinary  affections  present  symptoms  precisely 
similar  to  those  arising  from  calculus.  Hence  physical  demonstration  of 
a  stone's  presence  must  invariably  be  secured  before  diagnosis  is  made  or 
operation  attempted.  This  can  be  accomplished  by  means  of  the  metallic 
sound.  Stones  may  occasionally  be  felt  by  rectal,  vaginal,  or  bimanual 
palpation. 

Sounding  the  Bladder. 

The  patient  should  recline  upon  a  table  or  bed,  with  hips  elevated,  and 
the  bladder  moderately  distended  by  accumulated  urine  or  injection  of 
warm  water.  Anaesthesia  is  often  necessary  in  children,  or  where  examina- 
tion causes  much  suffering.     "  Gentleness,"  should  be  the  watchword  in  all 

Fig.  408. 


Type  of  sound. 

bladder  manipulations.  The  sound  is  made  of  steel,  about  17  ram.  in 
diameter,  with  a  dull,  short  beak  curved  upon  the  shaft  to  an  angle  of 
120°.     A  much  smaller  size  is  requisite  for  children. 

This  instrument  is  inserted  in  the  same  manner  as  a  catheter,  and  its 
point  carried  in  a  gentle  jerky  manner  systematically  over  the  entire 
vesical  area.  The  point  is  first  turned  into  the  base  and  trigone,  then 
above  the  pubis,  and  finally  over  the  other  portions  of  the  viscus.  If  no 
stone  is  found,  a  finger  is  inserted  into  the  rectum  or  vagina,  and,  while 
pressure  is  made  upon  the  abdominal  wall,  the  organ  is  again  gone  over. 
Still  failing,  the  urine  should  be  withdrawn  and  examination  repeated. 

These  successive  manoiuvres  having  been  carried  through  without 
loss  of  time,  further  efforts  should  not  be  made,  but  the  patient  quickly 
gotten  to  bed,  and  kept  warm.  Several  days  later  he  may  be  again 
sounded,  when,  with  the  familiarity  which  has  been  gained  in  the  former 
examination,  the  stone,  if  present,  will  generally  be  discovered.  Diag- 
nosis of  some  sacculated  calculi,  or  those  rare  instances  of  pediculation 
or  suspension  of  a  stone  by  a  lymph-band,  may  be  impossible  short  of 


VESICAL    CALCULI. 


679 


operative  exploration.     Non-discovery  of  a  stone  by  sounding  may  be 
taken  as  presumptive,  but  never  as  absolute,  proof  of  its  absence. 

When  the  instrument  comes  in  contact  with  a  calculus,  a  grating  sen- 
sation and  click  are  produced.  These  may  be  greatly  amplified  by  a 
sounding-board  attachment.    The  sensations  arising  when  a  stone  is  struck 


Fig. 409. 


Soundin2;-board  attached  to  sound. 


are  totally  different  from  those  arising  from  the  instrument  impinging  upon 
the  pelvic  bony  prominences,  or  from  rubbing  over  a  tumor  or  mucous 
membrane  coated  with  phosphatic  deposit.  Confusion  could  only  arise 
with  those  who  had  never  experienced  the  former.  The  presence  of  two 
or  more  stones  can  be  decided  by  seizing  one  in  the  jaws  of  a  lithotrite 
and  then  striking  another  with  the  instrument. 

A  stone  having  been  found,  it  is  important  to  determine  its  approximate 
size,  shape,  composition,  and  whether  or  not  it  is  encysted.  Size  and 
shape  can  be  ascertained  by  an  experienced  operator  by  passing  the  sound 
around  and  across  it,  but  the  better  plan  is  to  measure  the  distance  to 
which  the  blades  of  a  lithotrite  must  be  separated  to  grasp  it.  Compo- 
sition is  roughly  determined  by  the  size,  history,  condition  of  urine,  rough- 
ness of  surface,  and  contact  sensation.  Encysted  stones  are  always  found 
at  the  exact  spot  where  they  were  first  encountered,  and  cannot  be  moved 
or  seized  by  the  lithotrite. 

After  sounding  put  the  patient  to  bed,  keep  him  warm,  and  administer 
— if  it  has  not  been  done  beforehand — a  full  dose  of  quinine ;  also,  if 
pain  should  follow,  an  opium  (one  grain)  and  belladonna  (one-quarter 
grain)  suppository. 

Treatment. — The  presence  of  calculus  having  been  determined,  the 
imperative  indications  are  to  remove  it  and  to  treat  any  remaining  patho- 
logical conditions  of  the  bladder. 

Attempts  to  dissolve  the  stone  iii  situ  are  not  permissible ;  operation 
alone  must  be  resorted  to.  If  the  patient  is  run  down  and  exhausted,  a 
betterment  of  his  condition  by  rest  in  bed  and  milk  diet  should  be  at- 
tempted before  undertaking  removal  of  the  stone.  It  is  always  best  to 
thus  treat  the  patient  for  a  few  days  prior  to  operation.  Where  grave 
kidney  changes  exist,  palliative  treatment  by  anodynes  may  alone  be 
sanctionable. 

There  are  two  chief  methods  of  removing  a  stone  :  (1)  that  by  a  crush- 
ing and  (2)  that  by  a  cutting  operation,  and  it  is  often  most  difficult  to 
judge  which  is  best  for  the  case  in  hand. 

1.  Crushing  (lithotrity  and  litholapaxy)  is  generally  best  suited  to 
cases  where  the  stone  is  neither  too  large  nor  too  hard  ;  where  no  serious 
urethral,  prostatic,  bladder,  or  kidney  complications  exist ;  where  the 


G80      DISEASES    AND    INJURIES    OF    THE  URINARY   ORGANS. 

orgau  will  hold  three  or  four  ounces  of  Huid.aml  when  the  nucleus  is  also 
crushable.  Tumors  of  the  viscus  contra-indicatc  this  procedure  ;  also 
stricture,  unless  it  can  first  be  thorouirhly  relieved.  Conditions  of  para- 
lyzed, atonic,  or  sacculated  bladder,  while  unfavorable,  do  not  absolutely 
prohibit  its  employment.  .Sacculated  stone  is  usually  a  positive  contra- 
indication. 

For  crushing,  hard  stones  must  not  be  larger  than  three-quarters  of  an 
inch,  and  soft  ones  one  and  a  half  inches  in  diameter. 

2.  Cutting  operations  include  (a)  lateral  (and  bilateral)  or  sub-pubic 
lithotomy,  and  (6)  supra-pubic  lithotomy.  They  should  never  be  per- 
formed save  when  crushing  is  inadvisable,  a  is,  as  a  rule,  best  suited  to 
cases  presenting  grave  complications,  such  as  those  of  urethra,  prostate, 
and  kidney,  and  to  very  aged  persons  ;  also  where  it  is  necessary  to  com- 
plete the  removal  in  the  shortest  possible  time.  Children  stand  this 
operation  extremely  well.  Calculi  larger  than  one  and  a  (juarter  inches 
should  not  be  removed  by  this  route,  b  is  adapted  to  all  stones  larger 
than  one  and  a  half  inches,  to  those  complicated  by  tumors,  and  to  per- 
sons who  suffer  severely  from  "  urethral  fever." 

Calculi  in  the  female  bladder  are  removed,  according  to  size  and  com- 
plications, by  forceps  through  the  dilated  urethra,  crushing,  cutting 
through  the  vesico-vaginal  septum,  or  by  the  supra-pubic  operation. 

Stone  returns  in  about  4  per  cent,  of  all  cases  operated  upon  by  this 
method. 

Foreign  Bodies  in  the  Bladder. 

Foreign  bodies  are  frequently  met  with  in  the  bladder.  Such  include  : 
pieces  of  broken  instruments,  as  lithotrite  blades,  catheter  ends,  etc., 
bodies  inserted  into  the  urethra  with  lascivious  intent  or  to  relieve  reten- 
tion ;  also  those  coming  into  the  organ  through  wounds,  such  as  bullets, 
chips  of  shells,  bits  of  clothing,  splinters  of  wood  or  bone  ;  by  ulcerative 
processes,  as  foetal  remains,  sequestrse ;  or,  through  vesico-intestinal  fis- 
tulte,  feces,  fruit-stones,  or  parasites.  Hydatids  may  descend  from  the 
kidney. 

Bodies  when  retained  in  the  bladder  usually  form  nuclei  for  calculous 
deposit.  Symptomatology  and  diagnosis  correspond  with  that  of  stone. 
History  is  usually  most  obscure. 

Treatment. — Give  nature  a  fair  chance  to  expel  the  body.  Then  try 
to  extract  or  crush  with  the  lithotrite,  or  wash  out  with  the  lithotrity 
apparatus.  Glass  should  not  be  crushed,  and  care  must  be  taken  not  to 
close  the  lithotrite  strongly  upon  soft  substances,  for  fear  of  impacting  its 
blades.  These  measures  failing,  supra-pubic  cystotomy  should  be  promptly 
done. 

In.turies  of  the  Bladder. 

C'o)dimo)ts  are  often  followed  by  blood-tinged  urine  and  cystitis.  Treat 
as  if  beginning  acute  cystitis. 

Wounds  arise  from  direct  or  indirect  force  applied  from  within,  as 
instrumentation  or  rupture ;  or  from  without,  as  shot  and  stab  wounds, 
or  puncture  by  a  fragment  of  broken  pelvis.  Of  these  varieties  there 
are  two  great  classes :  the  '1)  intra-  and  (2)  extra-peritoneal. 

1.  Intra-peritoneal  tvounds  are  usually  accompanied  by  great  shock, 
hypogastric  pain,  inability  to  micturate,  nausea,  vomiting,  perhaps  hic- 
cough, signs  of  fluid  in  the  peritoneum,  and  later,  signs  of  peritonitis 


RETENTION    OF    URINE.  681 

and  absorption  of  urinary  products  by  the  peritoneura.  The  catheter 
(which  should  be  perfectly  aseptic)  may  bring  away  either  a  large  amount 
of  blood-tinged  or  clear  urine,  none  at  all,  or  pure  blood.  Perhaps  the 
instrument  can  be  inserted  unnaturally  far  and  be  felt  among  the  intes- 
tines through  the  abdominal  wall. 

Diagnosis  may  be  made  or  confirmed  by  injection  of  air  through  a 
catheter  and  noting  absence  of  tympanitic  bladder  distention,  while  the 
whole  abdomen  becomes  tympanitic  ;  or  by  exploratory  abdominal  section 
where  other  means  fail. 

Treatment. — Where  intra-peritoneal  rupture  or  other  wounds  exist, 
immediate  abdominal  section  in  the  median  line  low  down  must  be  per- 
formed. Any  foreign  body  present  must  be  removed  and  the  rent  sutured 
with  Lembert  stitches,  six  or  more  to  the  inch.  The  abdominal  cavity  is 
then  freely  washed  out  and  the  parietal  wound  closed,  leaving  in  a  glass 
drain  to  the  pelvis.  If  it  is  impossible  to  suture  the  tear,  the  tube  alone 
must  be  relied  upon.  The  urine  should  be  drawn  at  frequent  intervals 
for  the  first  week,  or  a  soft  catheter  may  be  tied  in  the  urethra. 

2.  Extra-peritoneal  wounds  are  often,  short  of  abdominal  section,  ex- 
ceedingly difficult  to  diagnose  from  those  involving  the  peritoneum. 
Usually  there  is  shock  and  copious  hemorrhage  from  the  urethra,  desire 
to  urinate  and  great  pain.  Extravasation  of  urine  generally  soon  appears 
in  the  perineum  or  lower  abdominal  wall. 

Treatment. — Perineal  section  and  drainage,  with  free  slitting  up  of 
infiltrated  areas,  are  the  prominent  indications. 

Retention  of  Urine. 

This  disorder  may  be  (1)  acute,  or  (2)  chronic,  complete  or  incomplete. 
Causes  may  be  mechanical,  functional  or  organic.  Retention  must  not  be 
confounded  with  suppression  of  urine. 

Causes. — 1 .  Impaction  of  calculi  or  foreign  bodies  in  the  urethra,  or 
changes  in  the  urethral  wall  due  to  strictures,  inflammation,  tumors,  out- 
side pressure,  enlarged  prostate,  blood-clots  or  abscesses,  also  nervous 
influences,  more  especially  after  operations  upon  the  genito-urinary  organs 
or  rectum,  are  the  most  common  causes  of  acute  retention. 

2.  Here  the  bladder  itself  may  be  at  fault,  being  powerless,  through 
paralysis  or  atony,  to  discharge  its  contents,  or  a  combination  of  causes 
usually  giving  rise  to  the  acute  variety  may  establish  the  chronic  retention. 

CoT'RSE. — The  bladder  becomes  over-distended  and  appears  as  a  rounded 
tumor,  yielding  a  flat  percussion  note  in  the  lower  abdomen  above  the 
pubic  symphysis,  and  may  extend  to,  or  in  old  cases  even  above,  the 
umbilicus,  and  without  care  give  rise  to  false  diagnosis.  In  long-standing 
cystitis  with  contracted  bladder  the  tumor  may  be  very  small  and  yet 
give  rise  to  the  utmost  distress,  while,  on  the  other  hand,  a  bladder  holding 
many  pints,  distending  the  whole  abdomen,  and  of  weeks'  duration,  may 
not  be  complained  of.  The  organ  very  rarely  ruptures  unless  subjected 
to  traumatism.  More  usually,  when  its  extreme  limit  of  expansion  has 
been  reached,  small  amounts  of  urine  are  forced  by  the  great  pressure 
through  the  obstruction  to  its  outflow,  and  constant  or  intermittent  drib- 
bling from  the  urethra  takes  place.  Where  incontinence  is  complained 
of,  the  state  of  the  bladder  should  always  be  examined  into.  Rupture 
of  the  urethra  behind  an  obstruction — especially  if  the  impediment  be  an 
old  stricture — is  bv  no  means  an  uncommon  result  of  extreme  retention. 


H82     DISEASES    AND    INJURIES    OF    THE  URINARY   ORGANS. 

The  back  pressure  in  the  ureters  and  pelvis  of  the  kidney  dilates  those 
parts,  or  may  develop  serious  disease  therein.  The  bladder,  after  relief 
of  severe  retention,  usually  remains  paralyzed  for  a  lonj^er  or  shorter 
time  and  is  highly  predisposed  to  putrefactive  and  inHammatory  changes. 

Symptoms. — If  acute,  there  is  much  pain  and  distress,  little  or  no 
urine  is  passed,  and  tumor,  as  above,  appears.  Pressure  in  the  hypogas- 
trium  is  intolerable.  A  finger  introduced  into  vagina  or  rectum  perceives 
the  bladder  pressing  down,  and  impulses  upon  the  abdominal  wall  are 
transmitted  to  it.  Typhoid  symptoms  accompany  some  cases  of  long 
standing.  When  onset  is  gradual  the  subjective  symptoms  are  less 
severe;  dribbling  of  urine  may  alone  be  complained  about. 

Treatment. — The  methods  of  relieving  retention  are:  the  catheter, 
if  it  can  be  passed :  supra-pubic  aspiration  repeated  twice  daily  for  days, 
if  necessary  ;  perineal  cystotomy,  which  latter  will  often  permanently  cure 
such  causes  as  enlarged  prostate  and  stricture.  When  obstruction  is  due 
to  vesical  calculus  or  tumor,  retained  blood-clots,  etc.,  supra-pubic  cyst- 
otomy is  preferable.  After-treatment  must  be  directed  to  removal  of  both 
cause  and  re.su Its  of  the  malady.  Hemorrhage  may  take  place  from 
engorged  vesical  veins  if  pressure  is  relieved  too  suddenly  by  rapid  with- 
drawal of  the  accumulated  urine.  Kidney  symptoms  must  be  treated  if 
they  arise. 

Suppression  of  Urine. 

This  is  a  most  dangerous  and  fatal  condition,  in  which  secretion  of  urine 
by  the  kidneys  ceases.  Previous  kidney  disease,  aggravated  by  the  effects 
of  anaesthesia  and  operations  upon  the  urinary  organs,  is  the  usual  cause, 
but  it  may  supervene  during  or  after  retention.  Symptoms  are  those  of 
acute  urremia.  No  urine  comes  into  the  bladder.  Treatment  is  almost 
universally  futile. 

Incontinence  of  Urine. 

Of  this  there  are  three  varieties:  1.  True  incontinence,  where  the 
urine  dribbles  as  fast  from  as  it  is  poured  into  the  bladder.  2.  Nocturnal, 
where,  independent  of  disease,  urine  is  passed  during  sleep.  3.  False 
incontinence,  the  result  of  retention. 

1.  ]May  be  due  to  atony  or  paralysis  resulting  from  spine  or  cerebral 
disease,  over-dilatation  of  the  urethra ;  or  certain  tumors,  or  localized 
hypertrophy  of  the  prostate  or  bladder,  interfering  with  the  vesical 
sphincter.     Treat  by  removing  the  cause,  if  possible. 

2.  This  is  practically  limited  to  children ;  is  an  involitional  act  depen- 
dent upon  reflex  inhibition  of  the  sphincter  vesicae  resulting  from  some 
irritation  of  the  alimentary  or  genito-urinary  tracts,  such  as  seat-worms, 
phimosis,  polypus,  stone  in  the  bladder,  or  indigestion. 

The  cause  should  be  removed,  and  tonics,  laxatives,  and  small  doses  of 
belladonna  will  be  useful.     The  child  should  never  be  punished. 


H,i:maturia. 

Hsematuria,  or  blood  in  the  urine,  is  usually  indicative  and  the  result 
of  disease  or  injury  at  some  point  in  the  urinary  tract,  but  may  result 
from  purpura  hjemorrhagica,  scurvy,  fevers,  or  to  the  ingestion  of  such 


OPERATIONS  UPON  THE  BLADDER.         683 

drugs  as  cantharides,  turpentine,  carbolic  acid,  or  to  the  presence  of  para- 
sites {Bilharzia  hcematobia).  It  may  be  continuous  or  paroxysmal,  accord- 
ing to  the  cause.  Its  presence  in  the  urine  is  indicated  by  the  color  and 
confirmed  by  the  microscope.  The  amount  of  blood  may  be  trivial  or 
enough  to  compromise  life.  If  it  remain  long  in  the  urine,  the  corpuscles 
decompose  and  the  liberated  hsematin  imparts  a  dark  smoky  hue  to  the 
urine. 

The  source  of  the  blood  may  be  approximately  determined  by  its  propor- 
tionate amount  and  the  occasional  presence  of  structures  recognizable  by 
the  microscope ;  also,  by  the  condition  of  the  blood ;  whether  decom- 
posed, clotted,  in  casts,  etc.  Usually,  when  of  kidney  origin,  it  is  inti- 
mately mixed  with  the  urine;  when  from  the  ureter  the  same,  or  in  long 
clots  or  fibrinous  casts ;  when  from  the  bladder  or  prostate,  it  comes  after 
or  in  the  last  portions  of  urine  ;  when  from  the  urethra,  in  the  intervals 
of  or  during  the  early  stages  of  urination — either  pure,  almost  so,  or  in 
casts  corresponding  to  the  urethra. 

Treatment. — Control  causes  as  elsewhere  described.  Clots  in  the 
bladder  soon  decompose  and  give  rise  to  serious  eflfects.  They  should  be 
dissolved  by  digestive  ferments,  broken  up  and  washed  out  by  the  lithot- 
rity  evacuator,  or  removed  by  supra-  or  infra-pubic  cystotomy. 

Pneumo-uria. 

Escape  of  gas  with  the  urine.  The  gas  always  originates  from  :  intro- 
duction through  instruments,  fermentative  processes  in  the  bladder,  or 
vesico-rectal  fistulse. 

Chyluria. 

Chyluria,  or  escape  of  milky  chylous  fluid  with  the  urine,  is  caused  by 
lodgment  of  the  filaria  or  hsematode  worm  in  some  portion  of  the  urinary 
lymphatic  system,  with  consequent  engorgement  and  rupture  of  lower 
lymphatic  channels  and  pouring  out  of  lymph  into  the  urinary  canal. 

Operations  upon  the  Bladder. 
Aspiration. 

The  surroundings  are  made  aseptic  and  the  outline  of  the  bladder 
mapped  out  by  percussion.  The  aspirator  needle  is  then,  avoiding  veins, 
thrust  through  the  abdominal  wall  one  inch  above  the  symphysis  pubis 
in  the  median  line.  Anaesthesia  by  freezing,  together  with  a  slight  skin 
incision,  renders  the  operation  almost  painless.  A  small  antiseptic  dressing 
should  be  applied  after  withdrawal  of  the  canula. 

Lithotrity. 

Lithotrity,  or  the  extraction  of  a  stone  by  crushing,  is  here  meant  to 
include  both  crushing  and  removal  of  resulting  fragments.  Sometimes 
the  name  lithotrity  is  applied  to  simply  crushing  the  calculus  and  allowing 
(as  in  former  times)  the  fragments  to  come  away  subsequently  with  the 
urine ;  litholapaxy  to  crushing  and  immediate  evacuation  of  the  debris. 

The  patient's  general  condition  having  been  improved  as  much  as 
possible,  all  strictures  well  dilated,  and  the  meatus  incised  if  it  is  nar- 


684     DISEASES    AND    INJirRIES    OF    THE   URINARY  ORGANS. 

row,  lie  is  placed  upou  a  table  with  his  hips  raised  six  inches  and  a  pillow 
beneath  the  knees.  Anaesthesia  is  always  necessary.  The  thighs  are 
separated  and  the  urine  drawn.  From  five  to  eight  ounces  (according  to 
its  capacity)  of  warm  water  are  injected  into  the  bladder  and  the  litho- 
trite  gently  inserted.     The  blades  after  introduction  should  look  upward 


Fig.  4)0. 


Fig.  411. 


.laws  of  Bigelow's  lithotrites,  e.xact  sizf . 


Jaw  of  fenestrated  lithotrite. 


and  rest  upon  and  slightly  depress  the  floor  of  the  organ.  Now,  holding 
the  handle  of  the  instrument  firmly  with  one  hand,  pull  out  the  sliding  or 
"  male  "  blade  two  inches.  Wait  a  second  to  let  the  stone  settle  and  then 
push  the  blade  home  again.  If  the  stone  is  caught  throw  on  the  screw 
mechanism  until  the  calculus  is  securely  fastened  between  the  jaws.   Lower 


Fig.  412. 


Ordinary  lithotrites. 


the  handle  to  carry  the  stone  and  blades  away  from  the  bladder-wall.  If 
there  is  any  resistance  to  this  movement  mucous  membrane  probably  has 
also  been  caught  and  the  stone  must  be  let  go  and  again  ensnared.  Other- 
wise the  blades  are  at  once  screwed  together  until  the  calculus  is  crushed 
between.  Then  each  resulting  fragment  must  be  likewise  caught  and 
crushed.     If  the  stone  -does  not  at  once  fall  into  the  instrument,  as  above, 


OPERATIONS  UPON  THE  BLADDER. 


685 


the  blades  are  reopened  and  carried  above  the  symphysis  by  depressing 
the  handle.     This  failing,  they  are  rotated  through  a  half  circle  from  side 


Handles  of  Bigelow's  lithotrites. 
Fig.  414. 


Position  of  lithotrite  in  crushing  stone.     (Listox.) 
Fig.  415. 


Seizing  stone  when  behind  prostate  with  lithotrite.     (Erichsen.) 

to  side,  always  open  to  prevent  pushing  the  stone  out  of  reach.  Again 
failing,  the  blades  are  rotated  until  they  point  to  the  rectum,  the  handle  is 
raised,  and  the  bladder  behind  the  prostate  explored,  always  remembering 


086     DISEASES    AND    INJURIES    OF    THEURINARY   ORGANS. 

to  carry  the  jaws  away  from  the  hhidder-wall  before  crusliing.     A  stoue 
having  been  caught  in  any  situation  and   crushed,  the  fragments  always 

Fig.  416. 


Removal  of  fragments  bv  Bigelow's  evacuator.     (Erichsen.) 

fall  vertically  and  can  be  secured  by  the  first  or  last  described  manoeu- 
vres and  successively  crushed.  When  all  have  been  broken  to  small 
fragments,  the  blades  are  screwed  firmly  home  and  the  instrument  with- 

FiG.  417. 


Bigelow's  apparatus  for  removing  fragments. 

drawn.     A  large  and  powerful  crusher  may  be  used  to  break  large  or 
very  hard  stones  and  a  smaller  one  to  deal  with  the  fragments. 

Now  introduce  the  largest  evacuating  catheter  that  the  urethra  will 


OPERATIONS    UPON    THE    BLADDER. 


687 


accommodate,  allow  all  fluid  to  escape  from  the  bladder,  and  then  inject 
into  it  about  three  ounces  of  water.  Connect  the  bulb  with  the  catheter 
and  inject  rather  suddenly  from  it,  by  compression,  about  as  much  more. 
Quickly  release  it,  when  the  return  current,  induced  by  expansion  of  the 
bulb,  will  draw  into  it  a  quantity  of  debris  and  fragments.  Give  these 
time  to  settle  into  the  receiver  below  the  bulb,  and  then  repeat  the  act  again 
and  again  until  no  more  fragments  are  withdrawn.  Great  precaution  must 
be  taken  to  ascertain  previously  the  extreme  capacity  of  the  bladder  and 
not  to  inject  more  fluid  than  it  can  hold  without  tension.  Otherwise 
it  may  be  ruptured.  The  evacuator  is  then  taken  out  and  the  organ 
explored  by  the  sound.  If  any  fragments  remain  they  must  at  once 
be  crushed  and  removed.  Dangers  to  be  feared  are :  suppression  of 
urine,  rupture  of  the  bladder,  and  impaction,  bending  or  breaking  of 
the  lithotrite  while  in  the  bladder. 

Perineal  Cystotomy  (and  Lithotomy). 
There  are  two  methods  of  performing  this  operation,  lateral  and  median. 

Lateral  Perineal  Cystotomy  {and  Lithotomy). 

The  bowels  are  previously  well  cleared  by  laxatives  and  an  enema 
just  before  operation,  and  the  parts  well  shaved  and  cleansed.  Anaes- 
thesia is  essential.  The  hips  are  brought  to  the  edge  of  a  table  and 
the  legs  fastened  in  the  "  lithotomy  position  "  by  bandages,  shackles,  or 
a  crutch.  The  urine  is  drawn,  the  bladder  moderately  distended  by 
injection  of  warm  water,  and  a  centrally  grooved  staff  introduced  into 
it  and  held  steadily  upright  in  the  median  line  against  the  under  surface 
of  the  pubis  by  a  skilled  assistant. 


Fis.  418. 


Fig.  419. 


Method  of  securing  hand  and 
foot  for  lithotomy.   (Druitt.) 


Position  of  patient  and  line  of  incision  in  lateral 
lithotomv. 


The  surgeon  sits  facing  the  perineum  between  the  patient's  legs.  He 
inserts  his  left  index-finger  into  the  rectum  to  make  certain  that  it  is 
empty,  to  cause  it  to  contract  and  to  act  as  a  guide ;  and  with  his  right 


688      DISEASES    AND    INJURIES    OF    T  H  E  U  Rl  N  A  R  Y   ORG  A  NS. 

hand  makes  a  cutaneous  incision  from  a  point  in  the  ra])he  one  and  a  (|uarter 
inches  in  advance  of  the  anal  margin,  downward  and  outward  to  a  point  on 
a  level  with,  but  one-third  nearer  to,  the  left  tuber  ischii  than  the  anus. 

Fig.  420. 


Grooved  staff  for  lithotomy. 


This  incision  divides  skin,  superficial  fascia,  the  external  hemorrhoidal,^ 
and,  perhaps,  the  superficial  perineal  vessels  and  nerves.  A  finger  now 
thrust  into  the  wound  locates  the  staff,  and  all  structures  are  divided 


Fig.  421. 


Lithotomy  knife. 

down  thereto,  and,  the  finger  acting  as  guide,  the  point  of  the  knife  is 
engaged  in  the  groove.  This  cut  severs  the  transverse  perineal  muscle 
and  artery,  the  lower  border  of  the  triangular  ligament,  and  punctures 


Fig.  422. 


Mode  of  cutting  into  the  bladder  and  liolding  knife.    (Liston.) 

the  accelerator  urintc  muscle  and  urethra.  Now,  while  the'knife  is  held 
in  a  horizontal  position  and  deviated  slightly  to  the  right,  it  is  pushed 
along  the  groove  into  the  bladder.  A  gush  of  water  through  the  wound 
announces  that  the  viscus  has  been  entered.     This  cut  divides  the  mem- 


OPERATIONS    UPON    THE    BLADDER. 


689 


branous  urethra  and  floor  of  the  pi'ostate.  As  the  knife  is  withdrawn  its 
handle  should  be  depressed  so  as  to  deepen  the  prostatic  incision.  Any 
subsequent  cutting  that  may  be  necessary  should  be  done  with  a  hernia 


Fig.  423. 


Lateral  lithotomy.  Incision  of  the  neck  of  the  bladder  as  seen  from  within.  A  is  a, 
rent  in  the  wall  made  by  introduction  of  the  finger.  B  is  an  extension  of  the  incision 
involving  only  the  mucous  membrane.     (Stimson.) 

knife  or  blunt-pointed  bistoury.     The  staff  is  next  removed  and  the  left 
index-finger  thrust  through  the  wound  into  the  bladder. 

If  the  perineum  is  very  deep,  a  blunt  gorget  may  be  introduced  before 

Fig.  424. 


Lithotomy  forceps. 


Fig.  425. 


Lithotomy  scoops. 

the  staff  is  withdrawn.  This  terminates  the  operation  of  cystotomy,  but  if 
the  extraction  of  a  stone  (lithotomy),  foreign  body,  or  tumor  is  contem- 
plated, straight  or  curved  forceps,  guided  by  the  inserted  finger,  must  be 

44 


690     DISEASES    AND    INJURIES    OF    THE  URINARY  ORGANS. 


employed  for  the  purpose.  If  the  stone  is  found  to  be  too  large  for  ex- 
traction without  severely  bruising  or  stretching  the  parts  (which  is  always 
dangerous),  and  cannot  be  broken  by  forceps  or  lithotrite  into  more 
manageable  size,  perineal  extraction  must  be  abandoned,  and  the  supra- 
pubic operation  performed.  Blood-clots,  etc.,  should  be  flushed  out  of 
the  organ  before  the  patient  leaves  the  table.     No  sutures  are  required. 

DAN(iERS. — Wounding  of  the  rectum,  posterior  bladder  wall,  prostatic 
capsule,  or  prostatic  plexus  of  veins,  the  artery  of  the  bulb,  or  an  anoma- 
lous pudic  vessel,  constitute  the  chief  dangers.  Tearing  of  the  bladder  wall 
also  may  take  ])lace  in  removing  bodies  with  forceps. 

After-tkkatmkxt. — No  dressings  need  be  applied.    The  patient  should 
be  placed  upon  a  bed  with  mackintosh  and  draw  sheets — the  latter  to  be 
changed  as  often  as  required.     If  the  urine  docs  not  flow  out  freely  a 
canula  may  be  tied  in  the  bladder.     Primary  or  secondary  hemorrhage 
may  be  promptly  checked  by  ligation  or  cauterization 
Fig.  426.  of  the  bleeding  points,  if  they  be  in  sight,  or  by  insert- 

ing a  "shirted  catheter"  into  the  bladder,  and  pack- 
ing the  "shirt"  firmly  with  strips  of  gauze.  These 
failing,  direct  digital  pressure  by  relays  must  be 
kept  up  until  it  ceases.  During  the  first  few  days 
succeeding  operation  all  urine  escapes  through  the 
wound.  Then,  owing  to  slight  obstructive  swelling 
therein,  a  portion  may  come  through  the  urethra ; 
after  a  day  or  two  more,  tumefaction  subsides,  and  all 
again  passes  through  the  wound,  until,  as  it  gradually 
cicatrizes,  more  and  more,  and  finally  all,  is  passed  per 
iirethram.  Should  perineal  fistula  remain,  it  should 
be  stimulated,  or  its  edges  pared  and  sutured.  (See 
Urinary  Fistula.) 

Median  Perineal  Cystotomy  {and  Lithotomy). 

Preparations,  up  to  incision,  as  have  been  described 
for  the  lateral  operation.     Incision  is  made  exactly  in 
the  perineal  raphe  from  one  and  a  half  inches  above 
the  anal  margin  doAvnward  one  to  one  and  a  quarter 
Shirted  catheter.        inches.    The  left  iudex-finger  guarding  the  rectum,  the 
incision  is  carried  down  until  tlie  urethra  is  opened  and 
the  point  of  the  knife  engaged  in  the  groove  of  the  staflT  at  the  upper- 
most angle  of  the  wound. 

Now,  holding  the  knife  at  a  right  angle  to  the  perineum,  it  is  thrust 
along  the  groove  into  the  bladder,  slightly  enlarging  the  prostatic  wound 
as  it  is  withdrawn.  If  the  operation  has  been  undertaken  simply  for  ex- 
ploratory jjurposes,  the  incision  should  be  confined  to  the  membranous 
urethra  and  not  open  up  the  prostate.  Dilatation  of  the  prostatic  urethra 
and  vesical  exploration  are  then  effected  by  the  gradual  insertion  of  a 
finger. 

The  median  operation  is  only  applicable  for  exploration,  drainage,  and 
removal  of  small  tumors,  foreign  bodies,  or  stones  (under  one  inch  in 
diameter).  Lateral  incisions  into  the  prostate  and  perineum  will  render 
the  wound  more  capacious  for  removal  of  a  calculus. 


OPERATIONS  UPON  THE  BLADDER. 


691 


Supra-jnibic  Cystotomy  {and  Lithotomy). 

The  abdomen  is  made  clean,  and  the  patient  placed  in  the  usual  posi- 
tion for  abdominal  section.  A  rubber  bag  is  inserted  into  the  emptied 
rectum  and  distended  with  ten  to  fourteen  ounces  of  water.  This  raises 
and  steadies  the  bladder.  Now  the  bladder  itself  is  thoroughly  washed 
out  with  mild  (1  to  5000)  bichloride  solution,  and  moderately  distended 
with  warm  water  by  injection.  A  tape  or  rubber  band  wound  around 
the  penis  and  tied,  will  prevent  its  escape  by  the  urethra.  As  peritoneum 
does  not  descend  in  front  of  the  bladder,  it  will  be  observed  that  by 
these  measures  the  largest  working  space  between  the  pubis  and  peri- 
toneum is  thus  secured.  The  organ  is  now  mapped  out  by  percussion, 
and  an  incision  two  to  three  inches  long  in  the  median  line  is  made 
immediately  above  the  pubic  symphysis,  and  carried  down  to  the  linea 
alba,  which  is  divided  to  the  extent  of  two  inches  and  held  aside  with 
retractors. 

Fig.  427. 


India-rubber  bag  for  distending  rectum. 

The  bladder  surface  is  now  exposed  freely  with  the  knife-handle.  If 
peritoneum  is  present  it  is  displaced  upward  out  of  harm's  way.  The 
vesical  wall  is  now  picked  up  on  either  side  of  the  median  line  with  catch 
forceps  or  sutures,  and  incised  vertically  between  them  in  the  median  line 
to  the  extent  of  three-quarters  of  an  inch.  A  finger  is  then  inserted  and 
the  organ  explored.  If  the  incision  prove  to  be  insufficiently  large  through 
which  to  deal  with  a  stone,  foreign  body,  or  tumor,  it  should  be  sufficiently 
enlarged  upward  and  downward  with  a  hernia  knife  or  scissors,  guided  by 
the  finger,  always,  however,  keeping  clear  of  peritoneum.  If  the  operation 
is  done  to  promote  continuous  drainage,  a  rubber  tube  with  a  crosspiece  to 


692     DISEASES    AND    INJURIES    OF    THE   URINARY   ORGANS. 

prevent  its  disappearance  should  be  fastened  into  the  bladder.  Otherwise, 
if  the  viscus  is  not  se])tic,  sutures  should  be  inserted  into  the  muscular  coat 
one-eighth  of  an  inch  apart.  The  superficial  abdominal  wound  must  not 
be  sutured,  so  that  should  the  bladder  stitches  give  way  or  leak,  the  ex- 
travasated  urine  will  readily  drain  away  and  not  be  forced  into  the  cellu- 

Fir..  428. 


Section  through  a  frozen  body  with  the  rectum  much  distended  (artificially).  1.  peri- 
toneal fold  in  front  of  bladder;  2,  the  bladder;  3,  internal  orifice  of  urethra;  4,  prostate 
gland:  5,  dorsal  vein  of  penis;  6,  bulbous  urethra;  7,  Cowper's  glands;  8,  upper  end 
of  membranous  urethra;  9,  recto- vesical  fold  of  peritoneum;  10,  prostate  gland:  11, 
abscess  in  bulbous  urethra.     (Gakson.) 


lar  tissues.  When  the  bladder  is  inflamed  or  otherwise  septic  no  sutures 
whatever  should  be  introduced,  but  simply  a  drain-tube  inserted.  In  either 
case  lightly  applied  anti.septic  dressings  should  be  kept  over  the  wound, 
and  the  patient  during  recovery  should  lie  first  on  one  side  and  then  on 
the  other,  to  j)revent  excoriation  from  urine  flowing  always  over  the  same 
surfaces.  A  foul  bladder  should  be  washed  out  through  the  wound  once 
or  oftener  daily.  The  wound  almost  invariably — often  too  soon — promptly 
closes.  Dangers  comprise:  rupture  of  either  rectum  or  bladder  from 
over-distention,  and  wounding  the  peritoneum.  Shou  Id  the  latter  accident 
occur  the  opening  in  it  should  be  sutured  and  fastened  into  the  upper 
angle  of  the  wound,  which  should  be  packed  with  gauze  and  the  bladder 
not  opened  until  a  few  days  later,  unless  it  is  urgent  to  do  so  at  once. 


PROSTATIC    TUBERCULOSIS.  693 


The  Prostate. 

Inflammation  of  the  prostate  gland  (prostatitis)  may  be  acute  or 
chronic. 

Acute  prostatitis  is  not  common,  and  usually  occurs  as  a  complication 
of  gonorrhoea,  but  may  arise  from  traumata  or  the  irritation  caused  by 
instrumentation,  calculi,  stricture,  or  cystitis. 

Symptoms. — There  is  dull  bearing- down  pain  in  the  perineum  and 
rectum,  the  parts  are  sensitive  to  touch,  and  micturition,  which  is  increased 
in  frequency,  greatly  aggravates  the  distress.  Cystitis  often  complicates. 
The  urine  may  be  blood-tinged.  Rectal  examination  reveals  the  prostate 
to  be  swollen,  elastic,  and  turgid — perhaps  to  such  an  extent  as  to  inter- 
fere with  or  prevent  micturition.  The  disease  may  gradually  subside, 
become  chronic,  or  progress  to  abscess  formation.  In  the  latter  case  con- 
stitutional and  local  signs  of  purulent  formation  arise  and  fluctuation 
may  be  demonstrated  by  rectal  examination.  This  may  open  into  the 
urethra,  perineum,  or  other  surrounding  structures,  and  perhaps  cause 
intractable  fistulas. 

Treatment. — Leeches,  succeeded  by  hot  fomentations,  laxatives,  and 
prompt  perineal  incision  w^hen  signs  of  suppuration  or  abscess  arise. 

Chronic  jirostatitis  may  follow  the  acute  variety  or  arise  more  insid- 
iously from  the  same  causes.  Symptoms  are  identical  but  of  less  degree, 
and  much  resemble  those  of  vesical  or  prostatic  calculus.  There  is  more 
or  less  inflammatory  interstitial  infiltration  and  enlargement.  Abscess 
may  likewise  develop.  The  patient  is  often  much  depressed  both  men- 
tally and  physically. 

Treatment. — Remove  the  cause  and  restore  the  impaired  health. 
Counter-irritation  by  blisters  or  leeching  of  the  perineum  is  efficient.  So 
also  are  cold  hip-baths.  The  prostatic  urethra  may  be  cauterized  by 
nitrate  of  silver.  The  disease  is  frequently  most  intractable,  and  certain 
extreme  cases  may  justify  perineal  cystotomy. 

Prostatic  Catarrh  (Prostatorrhcea). 

A  very  mild  form  of  irritation  or  inflammation  of  the  gland  accom- 
panied by  hyperseci'etion  from  its  gland  follicles  which  appears  as  a 
gleety,  colorless  discharge  from  the  urethra,  especially  after  straining  at 
stool  or  otherwise,  sexual  indulgence,  or  micturition.  This  escape  is  apt 
to  have  a  profoundly  depressing  effect,  as  the  patient  becomes  convinced 
that  it  is  semen  that  he  is  losing.  From  the  latter  it  is  differentiated  by 
the  microscope,  which  proves  the  absence  of  spermatozoa.  Its  causes  of 
origin  are  masturbation,  sexual  excess,  and  irritations  of  the  urethra. 
Removal  of  causes,  improvement  of  physical  condition,  laxatives,  and 
perineal  counter-irritation  by  small  blisters,  together  with  convincing  the 
patient  that  his  condition  is  not  serious,  generally  produce  a  cure.  Other- 
wise the  occasional  passage  of  a  bougie  of  large  calibre  or  cauterization 
of  the  prostatic  urethra  (as  above)  may  be  required. 

Prostatic  Tuberculosis. 

Prostatic  tuberculosis  is  an  uncommon  affection  and  almost  always 
secondary  to  tuberculosis  of  the  kidney,  testicle,  or  elsewhere.  The 
symptoms  correspond  with  those  of  chronic  inflammation,  stone,  and  cyst- 


69-t     DISEASES    AND    INJURIES    OF    THE   URINARY  ORGANS. 

itis,  but  usually  there  is  cachexia  and  unaccountable  constitutional  dis- 
turbauee.  Implication  of  the  bladder  and  other  contiguous  parts  speedily 
results.  Generally  it  is  not  diagnosal)le  until  tar  advanced.  Tubercular 
abscess  may  occur  at  a  late  stage,  when  tubercle  bacilli  can  be  found  in 
the  pus. 

Treatment. — The  treatment  should  be  directed  to  general  support  and 
early  incision  into  and  curetting  out  of  the  gland. 

Hypertrophy  of  the  Prostate. 

Hypertrophy  of  the  prostate  is  an  affection  of  advanced  life,  rarely 
occurring  before  the  fiftieth  year.  One-third  of  all  men  are  more  or  less 
aiiected ;  one-fifth  of  all  to  a  symptomatic  degree.  Pathologically  the 
affection  is  a  non-inflammatory  increase  of  the  normal  glandular  and 
stromal  elements  of  the  gland.  Both  constituents  may  hypertrophy  in 
equal  degree,  but  more  usually  the  former  greatly  preponderates.  The 
enlargement  may  affect  the  entire  organ  or  only  limited  portions.  Thus 
may  be  hypertrophied :  one  or  other  of  the  lateral  lobes,  both  lateral 
lobes,  the  middle  lobe,  or  the  whole  gland.  Or  even  smaller  areas  ma-y 
undergo  the  peculiar  change  and  produce  small  tumors  which,  when  near 
the  surface,  may  project  into  the  bladder  or  urethra.  Enlargements  of 
the  third  or  middle  lobe  and  those  of  the  last-mentioned  unusual  type 
are  alone  of  surgical  importance,  as  only  in  the  case  of  these  is  the  vesi- 
cal orifice  or  prostatic  urethra  obstructed  and  micturition  interfered  with, 
and  consequent  vesical  and  kidney  troubles  given  rise  to.  Causes  are 
sometimes  to  be  found  in  previous  urethral,  bladder,  or  prostatic  disease, 
but  more  often  none  can  be  assigned  save  that  of  age. 

Symptoms. — Unless  the  middle  lobe  is  involved,  or  the  lateral  ones  to 
unusual  degree,  no  symptoms  will  exist,  as  a  rule.  Thus,  even  great  gen- 
eral hypertrophy  may  remain  non-symptomatic,  while  but  slight  enlarge- 
ment of  the  middle  lobe  or  the  projection  of  a  small  localized  mass  into 
the  prostatic  urethra  may  give  rise  to  severe  symptoms. 

Slight  reduction  in  force  and  increase  in  frequency  of  urination  are 
usually  the  fii-st  signs  noted,  or  a  sudden  attack  of  retention  following  ex- 
posure may  be  the  primary  indication.  Later  there  develop  symptoms  of 
gradually  increasing  chronic  cystitis,  burning  pain,  very  frequent  and 
perhaps  painful  micturition,  changes  in  the  urine,  pain  and  sense  of  ten- 
sion in  the  perineum,  loss  of  sleep  and  exhaustion,  and  possibly  retention 
continuously  or  at  intervals.  Or  all  of  these  may  suddenly  follow  ex- 
posure when  no  prostatic  trouble  had  previously  been  suspected.  True 
incontinence  of  urine  may  result  from  the  enlargement  of  prostate  inter- 
fering with  the  action  of  the  vesical  sphincter.  A  crucial  symptom  of 
hypertrophy  is  the  finding  of  more  urine  in  the  bladder  after  its  appa- 
rent complete  emptying  by  urination.  This  is  due  to  the  enlargement 
interfering  with  complete  contraction  and  emptying  of  the  viscus,  and 
soon  decomposition  of  the  residual  urine  begins,  increases,  and  develops 
cystitis ;  as  a  result  of  which  stone  not  uncommonly  develops  in  the  blad- 
der or  prostatic  crypts  and  greatly  complicates  the  disease.  Still  later 
arise  symptoms  of  violent  cystitis  and  kidney  involvement.  The  enlarged 
gland  can  often  be  felt  per  rectum,  and,  by  pressure  thereinto,  may  cause 
flattening  of  the  stools. 

Diagnosis. — In  every  case  of  vesical  irritation  in  men  over  fifty  the 
catheter  should  be  passed  after  the  patient  has  urinated,  and,  if  residual 


HYPERTROPHY    OF    THE     PROSTATE, 


695 


Fig.  429. 


urine  is  found,  a  diagnosis  of  prostatic  enlargement  may  be  arrived  at. 
This  may  be  verified  by  rectal  examination,  and  often  also  by  the  difficulty 
encountered  in  passing  the  catheter  or 
other  instrument  through  an  irregu- 
larly hypertrophied  gland.  However, 
by  these  methods  we  have  only  recog- 
nized enlargement ;  its  cause  may  yet 
be  due  to  tumor  or  prostatic  calculus. 
The  history,  symptoms  and  progress 
can  alone  differentiate  its  exact  nature. 
Treatment. — For  the  milder  de- 
grees nothing  more  will  be  required 
than  that  the  patient  shall  be  provided 
with  and  instructed  in  the  use  of  a  soft 
catheter,  with  which  for  the  balance 
of  his  life  he  must  draw  off"  the  re- 
sidual urine  every  time  after  he  uri- 
nates, in  order  that  the  bladder  may 
be  kept  empty  and  free  of  irrita- 
tion.    Even  under  the  most  favorable 

conditions,  and  particularly  after  exposure,  cystitis  or  retention,  or  both, 
may  occur.      Retention  must  be  relieved  by  the  passage  of  a  soft  or 


Rubber  catheter. 


Fig.  430. 


Prostatic  catheters. 


G96     DISEASES    AND    INJURIES    OF    THE    URINARY   ORGANS. 

metallic  catheter  of  larjije  curve  (see  Fig.  430)  to  mount  over  the  distorted 
third  lobe.  The  passage  of  the  latter,  when  difficult,  can  be  nuich  facili- 
tated by  the  guidance  of  a  iinger  in  the  rectum.  If  "  false  passages  " 
have  been  made  by  the  patient  or  others  in  attempting  to  relieve  the  ac- 
cumulation, aspiration  for  a  few  days  should  be  practised  until  the  sinuses 
have  a  chance  to  heal.  But  if  acute  inflammation  or  abscess  has  arisen, 
it  may  be  wise  to  at  once  perform  perineal  cystotomy. 

In  all  acute  complications  treatment  tis  for  acute  prostatitis  is  appro- 
priate. 

Long  continuance  of  prostatic  hypertrophy  with  bladder  complications 
will  demand  median  perineal  cystotomy,  whereby  both  pathological  pro- 
cesses may  at  the  same  time  be  relieved  and  often  entirely  cured.  Ex- 
cision of  the  obstructing  lobe  through  a  supra-pubic  incision  has  been  per- 
formed with  success,  but  no  greater  than  as  above. 

Tumors  of  the  Prostate. 

Tumors  of  the  prostate  are  practically  limited  to  carcinoma  and  sar- 
coma. Usually  they  are  secondary  ;  most  rarely  primary.  Symptoms  at 
first  simulate  those  of  senile  hypertrophy,  but  the  growth  increases  with 
rapidity  and  soon  gives  rise  to  more  or  less  hemorrhage,  often  in  the  in- 
tervals between  micturition.  Treatment  can  only  be  palliative.  Supra- 
or  infra-pubic  cystotomy,  with  curetting. and  thorough  drainage,  or  simple 
lavage  of  the  bladder,  often  prove  of  the  greatest  comfort. 

Prostatic  Calculi. 

Calculi  not  infrequently  develop  in  the  follicles  of  the  prostate,  owing 
to  irritation  or  obstruction  thereof  by  inflammation,  tuberculosis  or  tumors. 
The  stones  may  be  solitary  or  in  great  number.  Where  multiple  and  in 
contact,  facets  mark  the  points  of  junction.  Symptoms  do  not  differ  from 
those  of  chronic  prostatic  and  bladder  inflammation.  Sometimes  the 
catheter  may  make  their  presence  known  by  grating  as  it  passes  through 
that  portion  of  the  urethra ;  or  they  may  be  discovered  by  rectal  examina- 
tion. Most  frequently  their  presence  is  unsuspected  until  perineal  cyst- 
otomy is  done  to  relieve  bladder  symptoms — another  advantage  to  the 
credit  of  that  operation  as  compared  with  the  supra-pubic.  A  fragment 
which  can  be  recognized  may  be  passed  by  urethra. 

Treatment. — Perineal  cystotomy  and  shelling-out  of  the  calculi  by 
fingers,  gouge  or  forceps. 

The  Urethra. 

Congenital  Malformations. 

Congenital  malformations  of  the  urethra  comprise :  partial  or  entire 
absence,  epispadius,  hypospadius,  termination  in  the  top  of  the  glans 
penis,  and  imperforate,  contracted  or  multiple  meatus  urinarius. 

Epispadias,  a  defect  in  the  roof  of  the  canal,  is  generally  complete,  but 
may  be  incomplete.  When  in  conjunction  with  vesical  exstrophy  of 
either  sex  (and  it  rarely  exists  otherwise)  the  defect  always  extends  from 
bladder  to  meatus — the  complete  variety.  In  males  impotence  is  a  usual 
result. 


PROLAPSE    OF    URETHRA, 


697 


^^r- 


Treatment. — The  treatment  of  the  complete  variety  is  usually  unsatis- 
factory, but  cure  may  be  attempted  by  freshening  the  edges  of  the  split 
urethra  and  suturing  thereto,  over  a 

catheter,  long  strips  of  integument  Fig.  431. 

partially  separated  from  the  hypo-  ^ 

gastrium  or  scrotum.  Similar  plastic 
operations  succeed  better  with  less 
extensive  defects. 

Hypospadias,  defect  of  the  lower 
portion  or  floor  of  the  urethra,  is 
very  much  more  common  than  epi- 
spadias, but  usually  affects  a  smaller 
extent  of  the  canal.  It  is  unusual 
in  the  female.  Complete  and  ex- 
tensive posterior  hypospadius  in  the 
male  is  associated  with  cleft  scrotum, 
and  results  in  impotence. 

Treatment. — When  the  open- 
ings are  close  to  the  meatus  often 
no  treatment  will  be  necessary,  but 
when  situated  further  back  may  be 
relieved  by  dissecting  flaps  from  the 

junction  of  skin  a]id  urethral  mucous  membrane  and  suturing  them  across 
a  small  catheter  placed  in  the  urethral  gutter.  Or,  these  flaps  may  be 
spHt,  the  lower  portions  sutured  over  the  catheter,  and  the  upper  portions 

Fig.  432. 


Complete  hypospadias.     (Smith.) 


Urethroplasty.     (Smith.) 

stitched  over  all.     Many  other  ingenious  methods  of  closing  these  defects 
are  applicable  to  certain  cases,  but  cannot  be  described  here. 


Prolapse  of  Urethra. 

Prolapse  of  the  urethra  occui'S  only  in  females ;  usually  in  children.  A 
mass  of  congested  urethral  mucous  membrane  with  perhaps  a  portion  of 
that  of  the  bladder  protrudes  from  and  more  or  less  obscures  the  meatus. 


698     DISEASES    AND    INJURIES    OF    THE   URIXARY   ORGANS. 

When  the  prolapse  is  acute  these  tissues  may  be  inHained,  oedematous, 
and  give  rise  to  retention  of  urine.  The  urethra  in  all  cases  is  much 
dilated.  The  causes  are  such  as  give  rise  to  relaxation,  tenesmus,  or 
straining. 

Tkkatment. — Acute  varieties  may  be  reduced  by  continuous  gentle 
pressure  and  manipulation.  If  irritative  distre.ss  attend  the  chronic  or 
constantly  recurring  forms  ^urethrocele)  the  condition  can  safely,  speedily 
and  permanently  be  relieved  by  making  a  half-inch  longitudinal  incision 
from  without  into  the  lower  urethral  wall  just  behind  the  meatus.  This 
is  carried  down  until  urethral  mucous  membrane  is  exposed.  A  large 
bougie  is  then  carried  into  the  canal  and  mucous  membrane  is  pulled 
through  the  wound  until  all  prolapsed  portions  or  redundancy  disappear. 
Sutures  are  then  passed  through  the  edges  of  the  wound,  including  the 
distal  extremities  of  mucous  membrane  drawn  through  it.  The  mem- 
brane external  to  the  stitches  is  now  cut  off  and  the  threads  tied  down 
firmly. 

Urethritis. 

Urethritis,  or  inflammation  of  the  urethra,  exists  either  as  a  simple 
(non-contagious)  or  specific  (contagious)  disease.  Either  vai'iety  may  be 
acute  or  chronic. 

Simple  (or  non-specific)  urethritis  may  arise  as  a  consequence  of  acrid  or 
decomposed  urine,  menstrual  or  vaginal  discharges,  exposure,  excessive 
venery,  drugs,  alcoholism,  seat-worms,  instrumentation,  or  wounds.  The 
symptoms  are  heat  and  burning  pain  in  the  urethra,  increased  and  painful 
micturition,  pouting  of  the  meatus,  and  later,  muco-purulent  discharge. 
Diagnosis  from  the  contagious  form  is  generally  impossible  in  the  early 
stages,  but  the  subsequent  course  and  absence  of  gonococci  in  the  discharge 
will  distinguish  the  two.  Our  opinion,  for  prudential  reasons,  should  be 
very  guarded  :  always  deciding  iu  favor  of  the  simpler  disorder  when 
slightest  doubt  exists,  and  invariably  directing  discontinuance  of  sexual 
intercourse  until  cure  is  complete. 

Treatment. — Discover  and  remove  the  cause,  if  it  still  exists,  and 
treat  as  if  the  specific  variety.  The  affection  is  subject  to  the  same  com- 
plications as  gonorrhoeal  urethritis,  but  usually  subsides  spontaneously  in 
from  six  to  ten  days. 

Specific  or  Gonorrhoeal  Urethritis.     (  Gonorrhoea.) 

An  acute,  specific,  infectious  inflammation  of  the  urethra,  having  a 
definite  period  of  incubation,  and  always  attended  by  the  presence  of 
gonococci. 

In  females  urethral  gonorrhoea  is  of  trivial  importance,  existing  only 
as  a  complication  of  specific  vaginitis. 

Cause. — Direct  or  indirect  contagion ;  usually  the  former  in  sexual 
congress. 

Symptoms. — The  symptoms  depend  much  upon  the  extent  of  urethra 
involved  and  are  generally  first  noted  on  the  fourth  day— rarely  as  early  as 
the  second  or  as  late  as  the  seventh  ;  when  uneasiness  "and  smarting  at  the 
meatus  and  along  the  urethra,  accompanied  by  slight  mucous  discharge 
and  scalding  urination,  are  observed.  These  signs  increase  in  severity  for 
an  average  of  two  days,  by  which  time  the  lips  of  the  meatus  are  red  and 
much  swollen,  there  is  slight  oedema  of  the  prepuce,  the  glans  penis  is 


URETHRITIS.  699 

turgid  and  glossy,  painful  erections,  especially  during  sleep,  occur,  mictu- 
I'ition  is  exceedingly  painful,  perhaps  difficult  or  impossible,  and  the  dis- 
charge changes  to  a  creamy  white  color  and  consistency,  becomes  copious 
in  amount,  and  may  be  tinged  with  blood.  Later  still  the  color  again 
changes  to  a  greenish  or  yellow  hue,  and,  microscopically,  will  be  found 
composed  of  pus,  mucus,  blood,  and  epithelium  containing  clusters  of 
gonococci.  There  is  swelling  and  turgescence  of  the  entire  penis,  vesical 
irritation  and  irritability  of  all  the  pelvic  organs.  The  penile  lymphatics 
and  inguinal  glands  may  be  enlarged. 


c 

^   ^  ^  i®'  tl 

5    ^  (@  v!g)  H 


Gonococci.     (Bumm.) 

a.  Cocci  from  a  jjure  culture. 

h.  Secretion  of  gonorrhojal  conjunctivitis, showing — epithelial  cell  covered  with  cocci; 
a  pus  cell  with  cocci  in  the  protoplasm ;  a  pus  cell  completely  filled  with  cocci ;  a  free 
mass  of  cocci  in  close  proximity  to  a  pus  cell. 

c.  Scheme  of  development  of  gonococci. 

This  condition,  as  a  rule,  lasts  from  ten  days  to  two  weeks,  after  which 
— depending  much  upon  extent  and  treatment — the  disease  gradually 
subsides  and  at  the  end  of  from  four  to  six  weeks,  if  all  goes  well,  the 
canal  has  regained  its  normal  condition,  but  even  under  these  most  favor- 
able circumstances  remains  more  liable  to  subsequent  reinfection  than 
before  the  primary  attack.  Much  more  frequently,  however,  and  espe- 
cially where  the  subject  has  had  previous  attacks,  complete  recovery  does 
not  take  place  for  months  or  even  years. 

Here  {chronic  specific  or  gonorrhceal  urethritis,  or  gleet)  there  persists, 
in  spite  of  all  treatment,  for  a  longer  or  shorter  period,  a  mucopurulent 
or  clear  viscid  discharge  with  slight  tenderness  of  the  urethra,  which 
upon  any  imprudence  or  exposure  may  become  much  aggravated  or 
relapse  into  subacute  gonorrhoea^  Chronic  persistent  urethral  discharges 
usually  indicate  the  presence  of  granulating  patches  in  the  urethra,  which 
almost  invariably  give  rise  to  stricture  later.  Long-continued  purulent 
discharge  may  cause  anaemia. 

Treatment. — Up  to  the  period  of  decline — the  first  week  or  two — 
treatment,  other  than  that  for  acute  complications,  should  consist  of  per- 
fect rest  in  bed  or  upon  a  sofa,  milk  or  other  easily  digestible  diet,  laxa- 
tives, perhaps  aconite  for  feverishness,  and  the  ingestion  of  large  amounts  of 
diluents.  iSTor  will  more  than  this  be  required  at  any  stage  if  the  discharge 
rapidly  diminishes  and  disappears  within  five  or  six  weeks.  Otherwise, 
should  discharge  or  other  symptoms  unduly  persist,  as  is  common,  sandal- 
wood oil,  cubebs,  or  copaiba  should  be  administered  by  mouth,  and  astrin- 
gent injections  into  the  canal  locally.  If  old  strictures  or  other  compli- 
cations are  present  they  must  be  eradicated,  for  otherwise  they  may 
proloug  or  prevent  recovery.  The  occasional  passage  of  a  large  bougie, 
or  cauterization  of  ulcerated  portions  of  the  urethra  by  nitrate-of-silver 


700     DISEASES    AND    INJURIES    OF    THE   URINARY    ORGANS, 


Fir,.  •l.'^4. 


Stick  in  a  urethral  port-caustic,  will  prove  of  great  advantage  in  certain 

inveterate  cases  of  chronic  urethritis  or  gleet. 

Complications. — Few  cases  of  gonorrhcea  escape 
without  one  or  more  complications.  The  principal 
of  these  are  as  follow  :  retention  of  urine,  chordee, 
acute  phimosis  or  paraphimosis,  inflammation  or 
abscess  in  the  prostate  or  Cowperian  glands,  epi- 
didymitis, orchitis,  cystitis,  nephritis,  inguinal  bubo, 
and  pyjemia.  Transplantation  of  infective  discharges 
to  other  mucous  membranes,  as  the  conjunctiva,  may 
occur  accidentally  and  produce  very  grave  compli- 
cations;  also  by  an  ill- understood  process  of  meta- 
stasis, gonorrhoeal  synovitis  or  arthritis  may  be  es- 
tablished in  one  or  more  joints. 

The  passage  of  instruments  and  too  early  resort 
to  injections  are  fruitful  causes  of  many  of  these 
complications,  by  carrying  the  infective  material  to 
the  deep  urethra  or  bladder. 


COWPERITIS. 

Inflammation  of  the  glands  of  Cowper  is  indi- 
cated by  a  sudden  or  gradual  circumscribed  swelling 
on  one  or  both  sides  of  the  urethra  in  the  perineum. 
This  may  be  distinguished  from  ischio-rectal  abscess 
by  the  usually  unilateral  and  localized  position  of 
the  former.  It  should  be  treated  by  poultices  until 
pus  is  formed,  then  by  prompt  and  free  incision. 


Stricture  of  the  Urethra. 


Uretliral  iiiiciiiuii  syr- 
inge.    Natural  size. 


Two  chief  varieties  of  urethral  stricture  are  recog- 
nized, (1)  true,  or  organic,  and  (2)  false,  or  func- 
tional. 

1.  A  permanent  oi'ganic  encroachment  upon  and 
diminution  of  the  urethral  calibre  by  contraction  of 
inflammatory  products  in  its  walls. 

2.  Is  temporary  or  intermittent,  and  results  from 
spasmodic  contraction  of  the  involuntary  muscles  of 
the  urethral  wall,  usually  caused  by  the  presence  of 

true  stricture  or  other  irritations  at  other  parts  of  the  canal — hence  it 
is  an  irritative  or  reflex  phenomenon. 

Organic  Stricture. 

Organic  stricture  may  develop  in  any  portion  of  the  urethra  except  the 
prostatic,  which  is  exempt.  They  are  rare  before  the  twenty-fifth  year, 
but  common  after  that  age.  One  or  many  may  be  present,  either  close 
together  or  widely  separated  ;  more  usually  there  is  but  one.  The  sites 
of  constriction  in  order  of  relative  frequencv,  are :  anterior  portion  of 
membranous,  posterior  portion  of  penile,  and  anterior  and  middle  por- 
tions of  penile  urethra.     Strictures  may  be  annular,  lateral,  or  tortuous 


STRICTURE     OF    THE    URETHRA.  701 

in  relation  to  the  urethral  axis  ;  and  permeable  or  impermeable  to  in- 
struments. 

Causes. — Almost  all  true  strictures  result  from  long-continued  irrita- 
tion and  inflammation  of  the  urethral  mucous  membrane  and  subjacent 
connective  tissues,  as  a  result  of  specific  urethritis.  A  few  are  caused  by 
simple  urethritis,  and  fewer  still  by  cicatricial  healing  of  wounds,  and 
ulcerative  or  necrotic  processes. 

Pathology. — The  pathology  of  stricture  is  simply  that  of  inflamma- 
tion of  mucous  membrane  and  peri-uretbral  tissues,  sometimes  embracing 
the  deeper  tissues  of  the  corpus  spongiosum  or  even  the  corpora  cavernosa. 
This  is  succeeded  by  inflammatory  deposit  which,  later,  organizes,  contracts 
to  a  greater  or  less  degree,  and  to  a  proportionate  extent  diminishes  the 
urethral  calibre  at  that  point.  Obstructive  symptoms  and  changes  in  the 
upper  urinary  organs  then  arise. 

Symptoms.- — -With  or  without  a  preceding  long-continued  purulent  or 
gleety  discharge,  interference  with,  increased  frequency  of.  and  dribbling 
of  the  last  few  drops  of  urine  after  micturition,  occur.  This  may  simply 
amount  to  diminished  strength  or  volume  of  the  stream,  gradually  increas- 
ing until  great  straining  is  required  to  pass  the  urine,  or  retention  takes 
place  ;  or  after  dietetic,  alcoholic  or  sexual  excess,  or  from  mere  exposure, 
complete  obstruction  and  consequent  retention  may  suddenly  occur,  and 
be  the  first  intimation  of  the  presence  of  stricture.  The  obstruction  may 
permit  of  false  incontinence  when  the  intra-vesical  tension  becomes  great, 
or,  if  neglected,  the  urethra  may  rupture  behind  the  stricture  and  produce 
extravasation  of  urine.  Rectal  hemorrhoids  and  prolapse,  likewise  her- 
ni?e,  may  result  from  straining  incident  to  partial  or  often-recurring  com- 
plete retention.  Severe  constitutional  symptoms  result,  in  neglected  cases, 
from  the  pathological  processes  originated  in  the  upper  urinary  tract  as 
the  result  of  urinary  obstruction  and  decomposition. 

Diagnosis. — Presumptive  diagnosis  may  be  made  from  the  above 
symptoms,  but  can  only  be  verified  by  instrumental  exploration  of  the 
urethra. 

Exploration  of  the  Urethra. 

The  patient  should  urinate  and  recline  ujDon  a  flat  surface.  A  dose  of 
quinine  (10  grains)  should  have  been  administered  several  hours  previously 
to  guard  against  subsequent  "  urethral  fever."  Diagnosis  of  a  marked 
stricture  can  be  roughly  made  with  an  ordinary  metal  dilating  bougie,  but 

Fig.  4.35. 


Metal  bulbous  bougie. 
Fig.  436. 


Rubber  bulbous  bougie. 

accurate  and  satisfactory  exploratory  diagnosis  can  only  be  conducted 
with  bulbous  bougies  of  metal  and  rubber.  If  the  meatus  is  contracted, 
it  should  be  divided.  (See  Meatomy.)     Then,  selecting  an  instrument  of 


702     DISEASES    AND    INJURIES    OF    T  H  E   U  RIN  A  R  Y  O  RG  ANS. 

about  25  mm.  in  diameter  (25  French  scale)  at  the  bulb,  the  penis  is  put 
slightly  upon  the  stretch,  and  the  bulb  passed  down  the  urethra  until  ob- 
struction is  encountered  or  the  bladder  entered.  If  the  former  obstruct 
the  instrument,  smaller  and  smaller  bulbs  are  successively  tried  until  one 
can  be  gently  i)ushed  through  the  obstruction  and  into  the  bladder.  Upon 
now  slowly  withdrawing  the  explorer,  resistance  will  be  met  so  soon  as 
the  shoulder  of  the  bulb  engages  in  the  constriction.  A  bend  or  mark  is 
then  made  upon  the  instrument  at  the  meatus.  Traction  is  then  made 
until  resistance  ceases,  and  another  mark  is  made.  Thus  we  have  diag- 
nosed a  stricture,  its  calibre,  situation,  and,  by  the  distance  between  the 
marks,  its  extent.  If  multiple  strictures  are  present,  they  are  consecu- 
tively discovered,  located,  and  measured  as  the  instrument  is  withdrawn. 
If  tlie  smallest  bulb  will  not  pa.ss  the  obstruction,  we  can  only  thus  diag- 
nosticate the  itresence  of  stricture  of  small  calibre,  beginning  at  a  certain 
distance  from  the  meatus. 

Care  must  be  taken  in  exploring  for  stricture  not  to  mistake  a  slight 
resistance  or  hitch  which  is  invariably  imparted  to  the  instrument  jis  the 
bulb  pa.-*ses  from  the  prostatic  to  the  membranous  urethra,  at  which  junc- 
tion the  bulb  catches  upon  the  posterior  layer  of  the  triangular  ligament, 
which  at  that  point  closely  invests  and  fixes  the  urethra.  Nor  must  a 
spasmodic  contraction  of  the  compressor  urethr?e  muscle  {false  stricture) 
be  mistaken  for  or  confounded  with  organic  stenosis.  The  former  may  be 
recognized  by  its  uniformity,  smoothness,  and,  perhaps,  intermittent  ten- 
sion. 

Treatment. — Strictures  are  treated  either  by  intermittent,  continuous, 
or  forcible  rapid  dilatation ;  by  division  by  the  knife,  from  within  out- 
ward (internal  urethrotomy),  or  from  without  inward  (external  ureth- 
rotomy), or  by  combinations  of  any  of  these  methods. 


Dilatation  of  the  Urethra. 

Intermittent  dilatation  is  applicable  to  and  most  successful  in  by  far 
the  largest  proportion  of  cases  met  with,  particularly  those  of  recent 
origin  and  annular  shape. 

Preserving  the  usual  precautions,  a  steel  bougie  of  diameter  equivalent 
to  that  of  the  stricture  is  warmed,  oiled,  and  gently  passed  through  the 
stricture.  Then  an  instrument  two  sizes  larger  is  introduced,  and  finally 
one  yet  a  size  larger,  which  is  kept  in  for  five  minutes  before  withdrawal. 
If  no  complications  follow,  this  should  be  repeated,  beginning  with  the 
second  largest  size  last  used,  every  three  to  six  days  until  the  stricture 
becomes  dilated  to  the  normal  calibre  of  the  urethra.  The  latter  can  be 
ascertained  approximately  by  measuring  the  penile  circumference,  for,  as 
pointed  out  by  Otis,  the  average  measurement  of  the  flaccid  penis  is  three 
inches,  and  the  diameter  of  the  urethra  32  mm.,  and  that  for  every  quarter 
inch  increase  or  decrease  in  the  circumference  of  the  penis  a  relative  dif- 
ference of  2  mm.  exists  in  the  urethral  calibre,  which  amount  should  be 
added  to  or  subtracted  from  the  size  of  the  normal  urethra  to  ascertain 
the  normal  calibre  of  any  individual  case. 

After  full  dilatation  has  thus  been  secured  and  maintained  for  a  few 
weeks,  the  patient  should  be  taught  how  to  pass  the  instrument,  and  be 
provided  with  a  full-sized  one  of  his  own,  which  he  must  pass  monthly, 
or  ofteuer  if  need  be,  for  the  balance  of  his  life. 

If  upon  each  successive  pa.ssage  of  the  instrument  great  irritation  or 


STRICTURE    OF    THE    URETHRA. 


703 


early  and  firm  recontraction  takes  place,  longer  intervals  between  dilata- 
tions must  be  allowed  to  pass,  or  other  methods  of  treatment  employed. 
General  anesthesia  is  but  rarely  necessary.  Nitrous  oxide  gas  may  be 
employed.  Cocaine  renders  the  operation  almost  free  from  pain,  but  has 
more  than  once  caused  death  when  thus  used. 

Continuous  dilatation  is  employed  where  the  stricture  is  only  permeable 
by  very  small  instruments  which  cannot  be  followed  up  by  larger  ones; 
in  certain  cases  associated  with  acute  or  chronic  retention  of  urine ;  and 
where  a  speedy  full  dilatation  is  desired. 


Fig.  437. 


Type  of  metal  dilating  bougie. 


Type  of  bougie  for  dilating  strictures  of 
the  meatus. 


The  method  is  applied  by  passing  an  instrument  two  sizes  smaller  than 
the  largest  which  the  stricture  will  admit,  and  tying  it  in  the  urethra  for 
a  number  of  days.  If  the  constriction  will  admit  even  a  small  instru- 
ment readily  this  can  be  carried  out  easily  enough,  but  assuming  that  the 
stricture  is  tortuous  and  of  very  small  calibre,  we  would  proceed  as  fol- 
lows :  Antesthesia  having  been  induced,  if  necessary,  a  fine  gum  catheter 
is  carried  down  to  the  stricture  and  manoeuvred  through  it  if  possible.  If 
this  pass,  well  and  good  :  it  should  be  tied  in  by  means  of  tapes  running 
to  a  piece  of  plaster  encircling  the  penis  behind  the  glans,  or  to  a  band- 
age encircling  the  waist.     But  failing  to   thus  j)ass  the   stricture,  the 


704     DISEASES    AND    INJURIES    OF    THE  URINARY  ORGANS, 


Fio.  439. 


I  / 


\J 


Filiform  whale- 
bone bougies. 


urethra  .*hould  be  filled  with  filiform  whalebone  bougies 
having  vari-shaped  extremities,  and  most  gently  attempting 
to  piiss  each  one  in  turn  until  finally  one  engages  in  and 
passes  the  stricture,  when  it  should  be  fa.stened  in  after  its 
fellows  have  been  removed.  This  also  failing  after  a  reason- 
able efibrt,  the  patient  .should  be  put  to  bed,  and  in  from 
twelve  to  twenty-four  hours  another  attempt  made.  But  if 
acute  retention  exists,  aspiration  or  external  perineal  ureth- 
rotomy should  be  immediately  resorted  to. 

After  the  instrument  has  remained  tied-in  for  a  day  or 
two — the  urine  meanwhile  constantly  trickling  through  or 
alongside  of  it — it  should  be  daily  removed  and  cleansed 
or  replaced  by  one  of  larger  size,  but  never  so  large  that  it 
does  not  fit  the  constriction  very  loo.sely,  for  otherwise  great 
irritation  will  be  set  up  and  more  harm  than  good  accom- 
plished. Under  influence  of  the  retained  instrument  the 
most  callous  and  obstinate  strictures  wnll  completely  dilate 
and  melt  away  in  from  a  few  days  to  two  weeks,  after 
which  event  intermittent  dilatation  should  be  started  and 
persistently  carried  out. 

In  all  probability  the  softening,  dilatation  or  "  melting  " 
of  strictures  under  this  method  i.s  not  due  to  the  exertion  of 
pressure,  but  to  some  unknown  influence  exerted  by  the 
presence  of  a  non-irritating  foreign  substance  in  the  urethra. 

Forcible  (immediate  or  rapid)  dilatation  is  used  to  pro- 
duce immediate  divulsiou  of  a  narrow  or  tortuous  stricture 
to  permit  easy  application  of  intermittent  dilatation  sub- 
sequently. 

For  this  purpose  a  silver  catheter  of  very  small  calibre, 
eighteen  inches  long,  is  introduced  into  the  bladder,  and 
over  it  are  slid,  one  after  another,  dilating  tubes  of  increas- 
ing size  until  full  dilatation  has  been  attained. 

Internal  urethrotomy  is  employed  in  certain  cases  where 
the  stricture  is  extremely  callous,  contracts  firmly  after 
each  dilatation,  or  is  very  persistent.  Cases  in  which  this 
proceeding  is  indicated  are  not  common.  The  stricture  must 
previously  be  dilated  sufficiently  to  admit  the  urethrotome. 

External  urethrotomy  is  applicable  to  a  class  of  cases 
presenting  very  dense  or  impermeable  stenosis,  and  especially 
when  complicated  by  fistulte  or  rupture  of  the  urethra ; 
where  all  other  methods  have  failed  to  give  a  temporary 
or  permanent  result ;  or  in  which  cystitis,  prostatic  disease, 
or  stone  coexist,  and  both  diseases  can  be  cured  by  this  opera- 
tion. No  matter  where  situated  or  how  bad,  all  strictures 
melt  down,  become  permeable  and  can  easily  be  treated 
subsequently  by  intermittent  dilatation  after  this  operation 
has  been  performed. 


Urethral  Fever. 

Urethral  fever  is  the  name  usually  applied  to  a  condition  of  pyrexia 
or  hyperpyrexia,  accompanied  by  more  or  less  severe  chills,  which  is  apt 
to  supervene  upon  perhaps  even  the  slightest  instrumental  interference  with 


CALCULI  AND  FOREIGN  BODIES, 


705 


or  injuries  of  the  urethra.  It  may  develop  immediately  after  the  passage 
of  a  sound  or  what  not,  but  more  usually  after  the  lapse  of  several  hours. 
The  causes  are  usually  reflex  nervous  phenomena,  but  may  be  septic 
absorption  on  occasion. 

Treat3IENT. — The  treatment  is  :  warmth  after  operations,  quinine,  ano- 
dynes, removal  of  any  instrument  from  the  urethra  or  bladder,  and  sus- 
pension of  all  surgical  interference  for  the  time  beitog. 

Urethral  Fistul.e. 

Urethral  fistulae,  as  a  rule,  result  from  abscesses  originating  in  the  glands 
thereof  in  connection  Avith  stricture  which  rupture  externally.  Also  fistulse 
may  arise  from  non- closure  of  operation  or  accidental  wounds  of  the 
canal  and  from  ulceration  incident  to  stones  or  foreign  bodies.  One  or 
many  may  be  present.  They  may  originate  from  any  portion  of  the 
organ,  but  most  usually  start  in  the  scrotal  or  perineal  divisions,  are 
multiple,  and  burrow  far  before  opening  externally,  as  upon  the  groin, 
thigh,  perineum,  scrotum,  etc.,  or  .into  the  rectum. 

Treatment. — Removal  of  the  cause  will  usually  be  followed  by  prompt 
closure,  otherwise  treat  as  described  under  Hypospadias  if  confined  to 
the  penis,  or  by  freely  slitting  up  the  sinus  to  its  point  of  origin  from  the 
urethra  and  packing  or  suturing  the  refreshed  margins  of  the  wound,  if 
opening  upon  the  perineum  or  scrotum. 


Calculi  and  Foreign  Bodies. 

Small  calculi  lodged  or  developed  in  the  urethra,  and  foreign  bodies 
introduced  from  without,  occasionally  demand  removal. 

Diagnosis. — The  diagnosis  is  usually  palpable  to  touch,  but  is  con- 
firmed by  the  urinary  obstruction  and  by  passing  a  sound. 

Fig.  440. 


Urethral  foreign-body  scoops. 
Fig.  44L 


Urethral  foreign-body  forceps. 

Treatment. — Elongated  bodies  can  generally  be  caught  and  removed 
by  urethral  forceps;  round  bodies  by  a  scoop.  Long  pins  can  often  be 
extracted  by  forcing  the  point  through  the  penis,  reversing  its  direction, 

45 


706     DISEASES    AND    INJURIES    OF    T  II  E  U  R  IN  A  R  Y  O  RG  ANS. 

and  pushing  the  head  toward  tlie  meatus.  If"  stricture  is  present  in  front 
of  the  calculus  it  must  be  dilated  at  once,  or  in  this  or  any  other  difficult 
case  direct  incision  upon  the  foreign  substance  thnnigh  the  lower  urethral 
wall  may  be  made,  removal  effected,  and  the  wound  allowed  to  heal  by 
granulation. 

Tumors. 

Vascular,  fibromatous,  neuro-fibroraatous,  papillomatous,  and  myxoma- 
tous neoplasms  occasionally  develop  from  the  walls  of  the  urethra  and 
project  into  its  cavity.  Cancer  and  tubercle  are  almost  never  here  located 
as  primary  growths. 

Symi'Tcims. — These  arc  made  up  principally  by  those  of  obstruction, 
localized  pain,  and,  perhaps,  hemorrhage.  The  growths  may  usually  be 
recognized  by  sight,  palpation  through  the  urethral  walls,  or  by  the 
bulbous  bougie. 

Treatment. — The  growths  may  l)e  removed  by  forceps  or  snood  if 
near  the  meatus ;  otherwise  by  an  incision  through  the  urethral  floor. 


Fig.  442. 


Fihro-vascular  Tumors. 

Fibro- vascular  tumors  at  the  orifice  of  the  female  urethra  T urethral 
caruncle  or  hemorrhoids)  are  quite  common,  exceedingly  painful  uptm 
motion,  micturition,  or  sexual  intercourse.  They  are 
easy  to  diagnose,  as,  in  conjunction  with  the  above 
symptoms,  there  are  seen  at  or  surrounding  the  meatus, 
one  or  more  intensely  red  and  sensitive  hemorrhoidal 
tumors  of  minute  size. 

Treatment. — Pick  them  u]i  with  a  forceps  or  tenacu- 
lum, snip  the  pedicle  with  scissors,  and  touch  the  wound, 
which  will  bleed  freely,  with  nitric  acid  or  the  cautery, 
being  careful  not  to  let  the  former  agent  spread  on  to 
contiguous  parts. 

Injuries  of  the  Urethra. 

Injuries  of  the  urethra  result  from  accidental,  self- 
inflicted,  and  surgical  traumata.  Severe  contusions  and 
lacerations  are  apt  to  be  followed  l)y  hemorrhage,  ex- 
travasation of  urine,  inflammation,  sloughing,  and  the 
subsequent  formation  of  cicatricial  or  traumatic  stric- 
ture. Rupture  of  the  urethra  may  be  occasioned  by 
retention,  pressure,  or  by  falls  upon  the  perineum,  as 
astride  a  plank.  In  either  case  the  injury  is  promptly 
followed  by  urinary  extravasation. 

Treatment. — Most  injuries  of  the  urethra  require 
but  treatment  upon  general  principles.    When  rupture 
or  other  wound  gives  rise  to  extravasation  or  retention 
of  urine,  and  a  catheter  cannot  be  passed,  immediate 
re.sort  to  perineal  cystotomy  must   be  made,  all  infil- 
Type  of  ordinary      trated  tissues  slit  up,  and  later,  when  all  swelling  has 
silver  catheter.        disappeared,  a  catheter  is  carried  through  the  entire 
urethra  at  frequent  intervals  as  the  wound  heals.    Sub- 
sequently, a  metal  bougie  should  be  passed  as  long  as  there  is  any  sign 
of  constriction. 


OFERATIOiSrs    UPON"    THE    URETHRA. 


707 


Operations  upon  the  Urethra. 

Catheterization. . 

Catheterization  can  only  be  learned  by  practice,  yet  a  few  guiding  direc- 
tions may  be  laid  down.  Observe  that  the  catheter  is  absolutely  clean, 
strong,  and  well  oiled.  The  patient  occupies  a  recumbent  position  with 
the  thighs  separated.  With  the  thumb  and  index  finger  of  one  hand 
gi'asp  the  head  of  the  penis  gently  and  turn  the  organ  up  over  the  pubis 
toward  the  abdominal  wall.     Then,  with  the  other  hand,  insert  the  iustru- 


FiG.  44.3. 


Introduction  of  the  catheter.     (Voillemier.) 

ment  into  the  meatus  and  along  the  urethra  until  the  point  reaches  the 
perineal  region,  when,  with  the  utmost  gentleness,  the  handle  is  carried  in 
a  vertical  arc  toward  the  patient's  feet  until  the  bladder  is  entered  and 
urine  flows.  But  if  any  resistance  is  felt  in  the  deep  urethra  a  finger 
should  be  inserted  into  the  rectum  to  act  as  a  guide  in  carrying  the  instru- 
ment through  the  deep  urethi'a  and  prostate. 


70S     DISEASES    AND    INJURIES    OF    THE    U  R  I  N  A  R  Y   ORG  ANS. 


Fig.  444. 


Catheterization  of  the  Female. 

If  the  sight  can  be  employed  there  will  be  no  difficulty  in  finding  the 
meatus  and  still  less  in  passing  the  catheter.  But  as  this  means  is  usually 
inadmissible,  the  procedure  maybe  accomplished  as  follows:  Select  a 
straight  gum  or  metal  instrument.  Insert  an  index  finger  into  the  vagina 
and  hold  it,  palmar  surface  up,  rather  firndy  against  the  upper  vaginal 

wall  in  the  median  line.  Now,  with 
the  disengaged  hand,  carry  the  catheter 
along  the  flexor  surface  of  the  inserted 
finger  and  it  will  almost  mvariably 
enter  the  ui'ethra. 

Internal  Urethrotomy. 

The  patient  having  been  prepared 
as  for  other  urethral  operations,  and 
the  urethra  suitably  dilated,  if  neces- 
sary, the  urethrotome  is  marked  at  a 
point  showing  the  distance  to  the  pos- 
terior extremity  of  the  stricture  by  a 

Fic.  44.->. 


m 


Urethrotome. 


Type  of  dilating  bougie  for  female  urethra. 


OPERATIONS    UPON    THE    URETHRA.  709 

rubber  band,  aud  inserted  until  tlie  knife  is  one-fourth  of  an  inch  behind 
the  constriction.  The  canal  and  stricture  are  then  put  upon  a  moderate 
stretch  by  screwing  apart  the  dilating  blades  of  the  instrument,  and  the 
knife  blade  is  protruded  one-eighth  of  an  inch  and  drawn  through  the 
entire  length  of  constriction.  The  knife  is  then  pushed  back  into  its  sheath, 
the  dilating  blades  half-closed  (not  wholly  closed,  for  fear  of  catching 
mucous  membrane),  and  the  instrument  withdrawn. 

If  the  stricture  is  quite  thick,  several  incisions  should  be  made  in  the 
same  line  after  each  time  separating  the  dilating  blades  to  a  greater  extent, 
until  the  stricture  is  cut  to  correspond  with  the  normal  urethral  calibre. 
All  cuts  should  be  made  in  the  roof  of  the  urethra  except  in  the  external 
one  and  a  half  inches  of  the  canal,  where  they  should  be  made  in  the  floor. 
Immediately  after  division,  a  full-sized  bougie  should  be  passed,  and  inter- 
mittent dilatation  kept  up  for  an  indefinite  time.  Hemorrhage  may  follow 
the  operation,  but  it  is  usually  slight.  In  other  case,  a  catheter  should 
be  passed,  and  a  bunch  of  cotton  bound  more  or  less  firmly  about  the  penis. 

External '  Urethrotomy. 

When  a  grooved  staff  or  other  instrument  can  be  inserted  into  the 
bladder,  this  operation  coincides  almost  precisely  with  median  perineal 
cystotomy.  But  if  the  stricture  is  impermeable  a  straight  staflf"  is  carried 
along  the  canal  as  far  as  it  will  go.  Incision  is  then  made  in  the  perineal 
raphe  until  the  point  of  the  staff  is  come  upon  and  healthy  urethra  divided. 
Each  side  of  the  split  urethra  is  sutured  and  held  by  a  silk  thread. 
Careful  dissection  is  then  made  in  the  direction  of  the  prostatic  urethra, 
a  finger  in  the  rectum  serving  as  a  partial  guide,  while  at  the  same  time 
guarding  that  cavity,  until  the  urethra,  usually  much  dilated  and  of  conse- 
quence more  readily  found,  is  opened  up.  This  event  will  be  announced 
by  a  gush  of  urine.  Any  well-marked  cicatricial  tissue  is  now  trimmed 
away,  and  the  wound  left  to  granulate  and  cicatrize.  The  passage  of 
bougies  should  be  started  a  few  days  later. 

Dilatation  of  the  Female  Urethra. 

Dilatation  of  the  female  urethra  is  accomplished  by  the  introduction 
thereinto  of  increasing  sizes  of  slightly  conical,  short,  straight  bougies  or 
plugs.  Fig.  445,  or  by  inserting  one  finger  after  another,  beginning  with 
the  fourth  and  ending  with  the  index.  Permanent  paralysis  may  result 
from  extreme  hyper-dilatation.  .  Temporary  incontinence  usually  follows 
even  slight  dilatation. 


CHAPTER    XX  I Y. 

DISEASES  AND  INJURIES  OF  THE  REPRODUCTIVE  ORGANS. 


THE   SCROTUM. 


In  cases  of  complete  hypospadias  the  scrotum  is  split  into  two  halves, 
each  containing  a  testicle,  or,  as  likely  as  not,  one  or  both  of  these  latter 
organs  may  be  undescended.  Such  cases,  together  with  fissure  or  absence 
of  the  penis,  give  rise  to  most  instances  of  so-called  hermaphrodism. 

The  veins  coursing  through  the  scrotal  walls  occasionally  become  vari- 
cose to  an  extreme  degree.  When  the  annoyance  or  pain  arising  there- 
from is  not  checked  by  wearing  a  suspensory,  the  vessels  may  be  ligated 
in  several  places  or  excised.  Where  great  redundancy  becomes  a  source 
of  discomfort,  large  oval  portions  of  the  scrotal  integument  may  be  cut 
away  and  the  wound-edges  closely  sutured  without  drainage. 

Elephantiasis. 

Elephantiasis  is  an  unusual  disease  of  the  scrotum  in  this  latitude,  con- 
sisting of  an  enormous  hypertrophy  of  the  skin  and  connective  tissues. 
The  penis  is  almost  always  similarly  involved.  Febrile  disturbance  is 
marked  in  the  early  stages,  but  lessens  as  the  hypertrophy  and  concomi- 
tant debility  increase. 

Treatment. — Certain  favorable  cases  may  be  cured  by  excision,  even 
if  the  proportions  of  the  growth  are  enormous.  For  this  purpose  the 
mass  is  elevated  and  constricted  at  its  base  with  a  rubber  band  or  other 
tourniquet.  The  penis  and  testes  are  then  exposed  by  deep  incisions  and 
dissected  from  the  mass,  which  is  then  cut  away  at  its  base.  The  wound, 
after  all  bleeding  points  have  been  secured,  is  dressed  antiseptically  and 
allowed  to  heal  by  cicatrization. 

Lymph  Scrotum. 

Lymph  scrotum  is  a  variety  of  hypertrophy  due  to  lymphatic  obstruc- 
tion'caused  by  the  presence  of  filaria  sanguinis  homiuis  in  the  higher 
lymph  vessels.  Attempts  to  remove  the  worm  are  alone  admissible  in  the 
Avay  of  treatment. 

Epithelioma. 

Epithelioma  (chimney-sweep's  cancer)  is  prone  to  develop  upon  the 
scrotum  of  those  of  any  age  who  work  amidst  soot.  Otherwise  it  is  a 
rare  affection.  The  growth  presents  the  same  characteristics  as  do  epi- 
theliomata  elsewhere  situated. 

Treatment. — Excise  the  mass  and  surrounding  tissues  embracing  the 
entire  thickness  of  the  scrotal  wall.  Suture  the  wound,  if  small,  other- 
wise allow  it  to  granulate  under  antiseptic  protection. 


THE    TUNICA   VAGINALIS. 


711 


Contusions  of  Scrotum. 

ContusioDs  usually  give  rise  to  extensive  blood  extravasations  between 
the  layers  of  the  scrotum,  with  great  discoloration  of  the  surface.  Abscess 
or  sloughing  may  result. 

Wounds. 

Wounds  are  treated  upon  the  general  principles  of  wound  treatment 
already  laid  down.  Should  the  testicle  prolapse  it  should  be  cleansed, 
returned  to  position,  and  the  skin  brought  together  over  it,  leaving  in  a 
small  drain-tube. 

The  Tunica  Vaginalis. 

Hydrocele. 

A  serous  effusion  into  the  peritoneal  sheath  of  the  testicle.  The  affec- 
tion may  be  (1)  congenital  or  (2)  acquired. 

1.  Congenital  Hydrocele  is  almost  always  found  in  young  children,  and 
is  clue  to  non-closure  of  the  communication  of  the  tunica  vaginalis  with  the 
peritoneal  cavity.  Congenital  or  early  acquired  hernia  frequently  com- 
plicates the  defect.  There  is  fluid  in  the  sheath  which  responds  to  the 
light  and  succussion  tests,  disappears  upon  pressure  and  lying  down,  and 
reappears  upon  removing  pressure  or  standing  up. 

Treatment. — Spontaneous  cure  usually  results  by  closure  of  the  peri- 
toneal communication  at  the  neck  of  the  sac.  A  truss  should  be  worn 
for  hernial  complication.  Do  not  attempt  tapping  or  injection  in  this 
variety  of  hydrocele. 

2.  Acquired  hydrocele  is  quite  common  in  childhood  and  after  middle 
life.  One  or  both  sides  may  be  involved — ^usually  but  one.  Some  form 
of  inflammation  is  generally  the  causative  factor. 
The  cyst  may  contain  from  an  ounce  up  to  a  quart 
or  more  of  fluid.  This  fluid  is  straw-colored,  clear, 
has  a  specific  gravity  of  about  1030,  coagulates 
upon  exposure  or  boiling,  and  is  made  up  almost 
wholly  of  albumen.  If  the  result  of  acute  inflam- 
mation the  serum  may  be  turbid  and  perhaps  con- 
tain blood  and  pus  corpuscles  ;  when  milky  the  color 
is  due  to  the  presence  of  spermatozoa,  which  have 
come  from  the  testicle  as  a  result  of  rupture  of  a 
cyst  of  the  gland  or  epididymis  into  the  vaginal 
tunic.  Cholesterine  crystals  commonly  are  present 
and  float  upon  the  surface  of  the  liquid. 

In  recent  cases  little  or  no  change  can  be  observed 
in  the  tunica  vaginalis,  but  in  those  of  long  standing 
and   especially   where  many   tappings    have   been 
made,  the  membrane  is  vascular,  much  thickened, 
and  excessively  tough.     Either  lying  loose  in  the  nal  tunic  of  the  testicle. 
sac,  attached  to  its  walls,  or  even  pediculated,  are  a.  testicle.  (Wyeth,  after 
sometimes  found  pea-sized  or  larger  dense  fibrinous  Lishaet.) 
bodies ;  cases   presenting  which   are   apt   to  suffer 

much  pain  or  neuralgia  and  to  persistently  relapse  in  spite  of  all  treat- 
ment until  the  bodies  are  found  and  removed.     The  shape  of  a  hydrocele 


Fig.  446. 


Hydrocele  of  the  vagi- 


712 


THE     REPRODUCTIVE    ORGANS. 


is  usually  pvriforui  but  lulhesious  in  the  sar  may  cause  it  to  assume  other 
shapes  or  eveu  divide  it  into  several  rjejjarate  cysts. 


Fig    447. 


^ 


-^ 


Fig.  448. 


Trocar  for  tapping  hydrocele. 

Symptoms. — Swelling  of  the  scrotum,  which  begins  below  ;  a  sense  of 
weight  and  occasional  dragging  pain  therein.  Tension  is  not  apparent  at 
first  but  soon  develops  and  becomes  more  and 
more  marked,  while  the  tumor  assumes  a  charac- 
teristic pyriform  shape.  If  very  large — espec- 
ially when  double — the  penis  is  entirely  retracted 
into  the  cyst  wall  and  upon  micturition  the 
urine  runs  down  over  the  scrotum.  Fluctuation 
is  marked  and  the  tumor  is  seen  to  be  translu- 
cent when  a  light  is  held  on  one  side  of  the 
swelling  and  looked  at  from  the  other,  while  a 
hand  shuts  off  all  extraneous  light  from  the 
observer's  eye.  It  cannot  be  reduced  to  the 
abdominal  cavity  and  gives  no  imi)ulse  when  the 
patient  coughs.  Occasionally  it  is  impossible  to 
distinguish  clouded  or  opaque  hydroceles  from 
tumors  of  the  te.sticle  until  incision  is  made. 

Treatment  may  be  (1)  palliative,  or  (2) 
radical. 

1 .  Tapping.  Cleanse  the  parts  and  by  the  light 
test  locate  the  position  of  the  testicle.  Grasp 
the  scrotum  and  make  it  tense  while  a  clean 
trocar  of  medium  size  is  plunged  into  the  cyst 
so  as  to  avoid  scrotal  veins  and  the  testicle. 
"Withdraw  the  pin  and  allow  the  contents  to 
drain  away  through  the  canula.  Subsequently 
a  small  antiseptic  dressing  retained  by  an  ad- 
hesive strap  will  be  required  for  a  few  days. 

2.  Radical  treatment  includes:  (a)  tapping 
and  injection  and  (h)  incision  and  drainage. 

a.  Injection  is  made  by  throwing  into  the  sac  through  the  canula,  after 
the  contents  have  been  withdrawn,  from  one  to  four  drachms  of  pure  tinc- 
ture of  iodine  or  five  to  ten  minims  of  liquefied  carbolic  acid  crystals. 


Tapping  a  hydrocele. 

(Bbyakt.) 


THE    TUNICA   VAGHNALIS.  713 

These  irritative  agents — when  carried  into  all  portions  of  the  sac — produce 
inflammation  and  subsequent  obliteration  of  the  cyst  cavity  by  universal 
adhesion  of  its  apposing  walls.  It  is  very  generally  successful  unless  the 
fibrous  bodies  above  mentioned  happen  to  be  present,  when  failure  will 
usually  ensue ;  also  it  is  quite  safe  and  free  from  unpleasant  consequences. 
The  attendant  pain  is  not  severe.  The  patient  should  recline  in  bed  or 
upon  a  sofa  for  a  couple  of  days. 

b.  Incision  and  drainage,  as  a  rule,  prove  most  efiectual,  and  are  equally 
safe  if  antiseptic  methods  are  pursued.  A  two-inch  incision  is  made 
through  the  scrotum  into  the  sac.  Fibrous  bodies  are  then  carefully 
searched  for,  and  removed  if  present.  The  sac  is  wiped  over  with  tinc- 
ture of  iodine,  a  small  drain-tube  inserted,  the  wound  sutured  about  its 
orifice,  and  an  antiseptic  dressing  applied.  The  tube 
should  be  removed  in  a  week.    This  method  must  Fig.  449. 

always  be  adoj^ted  when  infiammatory  complications         ^^_  ;v 
exist.  ' 

Hydrocele  of  the  Spermcitic   Cord. 

A  collection  of  serous  fluid  in  an  unobliterated 
portion  of  the  peritoneal  sheath  of  the  cord. 

Symptoms. — A  globular  or  oval,  tense,  fluctuating, 
irreducible,  freely  movable  tumor  is  located  at  some 
point  upon  the  spermatic  cord  external  to  the  internal 
abdominal  ring. 

Treatment. — The  treatment  is  as  for  vaginal 
hydrocele,  but  the  operator  should  make  certain  Encysted  hydrocele 
that  no  communication  with  the  abdominal  cavity  of  the  cord.  a.  testicle, 
exists  before  applying  radical  measures.  (Wteth.) 

Hydrocele  in  the  Female. 

Hydrocele  in  the  female  afiects  analogous  parts,  and  in  many  respects 
resembles  hydrocele  of  the  cord  in  the  male.  It  consists  of  a  localized 
collection  of  serous  fluid  in  some  portion  of  the  serous  tunic  of  the  round 
ligament  as  it  courses  through  the  inguinal  canal  to  be  inserted  into  the 
cellular  tissue  of  the  greater  labium. 

It  must  be  differentiated  from  hernia,  cysts,  and  varicosities  of  the 
labium.  Ti-eatment  is  identical  with  that  of  hydrocele  of  the  spermatic 
cord. 

Hematocele  of  the   Tunica  Vaginalis. 

Effusion  of  blood  into  the  tunica  vaginalis.  It  may  complicate  any 
form  of  hydrocele,  or  exist  independently.  The  usual  cause  is  contusing 
violence,  injury  by  the  trocar  point,  tearing  of  adhesions,  or  rupture  of  a 
vein. 

Symptoms. — A  heavy,  painful,  pyriform  (base  downward)  tumor  dis- 
tends the  tunic,  is  fluctuating,  flat  upon  percussion,  while  the  scrotum  is 
apt  to  be  tense,  livid,  and  ramified  by  distended  tortuous  veins.  The 
testicle  can  be  outlined  below  and  behind.  Pain  later  disappears,  but 
only  to  return  should  inflammatory  complication  arise.  The  tumor  is 
opaque  to  the  light  test,  and  does  not  transmit  impulses  when  the  patient 
coughs.     The  blood  may  be  absorbed,  break  down  into  a  viscid  consist- 


714  THE    REPRODUCTIVE    ORGANS. 

ency,  or,  rarely,  abscess  may  form.     Calcification  of  the  mass  has  been 
observed. 

Tre.\.tment. — Rest  in  bed,  elevation  of  the  scrotum,  and  cold  affusions 
thereto ;  leeches  in  the  line  of  the  cord  are  applicable  to  the  acute  or 
formative  stages.  If  at  a  later  time  resor|)ti()n  does  not  take  place  or 
inflammation  arises,  incision,  turning  out  the  clots,  and  drainage  as  in 
hydrocele  should  be  resorted  to. 

The  Spermatic  Veins. 
Varicocele. 

Varicosity  of  the  spermatic  and  pampiniform  veins  of  the  spermatic 
cord. 

This  condition  is  rare  after  the  fiftieth  year ;  early  manhood  and 
the  prime  of  life  are  the  chief  periods  of  origin.  Occasionally  the  dis- 
ease is  double  or  upon  the  right  side,  but  in  the  vast  majority  of  cases 
the  left  side,  and  it  alone,  is  involved.  The  theoretical  exi)lanations  given 
to  this  fact  are:  the  left  spermatic  vein  is  longer  than  the  right,  supplies 
the  larger  testicle,  opens  into  the  renal  vein  at  right  angles,  has  no  valve 
at  its  renal  outlet,  and  lies  close  upon  the  sigmoid  flexure  of  the  rectum, 
and  is  thereby  exposed  to  pressure  from  distention  thereof.  Great  exer- 
tion, strains,  constipation,  venery,  pressure  upon  the  cord  of  trusses,  and 
relaxed  scrotum  act  as  exciting  causes. 

SYMrTOMS. — AVhen  the  cord  is  searched  for  in  its  usual  position  a  mass 
much  resembling  a  bunch  of  worms  is  felt ;  it  is  compressible,  can  be  emptied 
by  pressure  or  upon  the  patient's  lying  down,  returns  upon  rising,  and 
greatly  distends  when  he  coughs  or  strains.  In  the  mass  can  be  felt  and 
isolated  the  whipcord  or  wire-like  vas  deferens.  Perhaps  the  tortuous 
veins  can  be  seen  distending  the  scrotum.  Pain  of  a  dragging,  dull,  dis- 
tressing, unnerving  character,  is  usually  present,  and  increased — as  is  the 
varicosity — in  warm  weather,  when  the  scrotum  and  other  tissues  are  more 
lax. 

From  malnutrition  incident  to  impeded  return  circulation,  the  testicle 
is  apt  to  atrophy  more  or  less,  also  to  become  tender  and  sensitive.  Grave 
mental  distress — principally  from  fear  of  sterility — often  accompanies  the 
diseiise. 

Treatment. — In  very  many  cases  comparative  relief  and  comfort  can 
be  secured  by  regulation  of  diet  and  bowels,  judicious  exercise,  tonics, 
cold  bathing  and  hip  baths,  and  wearing  a  well-fitting  suspensory  bandage 
or  bag.  Where  such  measures  fail,  ligation  of  the  veins  en  masse  should 
be  performed.  This  operation  invarialjly  gives  immediate  and  permanent 
relief  and  does  not  interfere  with  the  nutrition  or  activity  of  the  testicle. 

Ligation  of  the  Spermatic  Veins. 

The  scrotum  and  surroundings  having  been  rendered  aseptic  and  shaved, 
a  vertical  incision  down  to  the  veins,  two  to  two  and  a  half  inches  long, 
is  made  upon  the  antero-external  aspect  of  the  scrotum.  The  vas  deferens 
is  now  recognized  by  its  wire-like  feel  when  rolled  between  the  fingers  and 
isolated  behind  the  thumb  and  index  finger,  while  the  veins  are  all  kept 
in  front.  A  strong  catgut  ligature  is  now  passed  with  an  aneurism  needle 
between  the  veins  and  fingers,  separating  them  from  the  vas  at  the  upper- 


THE    TESTICLE.  715 

most  exposed  portion,  and  tied  tightly  about  the  varicose  mass.  The 
same  is  then  repeated  just  above  the  epididymis,  and  a  section  of  the  mass 
cut  out  between,  leaving  a  good-sized  button  of  tissue  at  each  point  of 
ligation.  A  small  catgut  or  rubber  drain  is  inserted,  the  wound  sutured 
and  dressed  antiseptically.  The  patient  must  be  kept  upon  his  back  in 
bed  for  a  week  subsequently. 

The  Testicle. 

Congenital  Abnormalities. 

One  or  both  testicles  may  be  absent  from  their  normal  position,  the  scro- 
tum, incident  to  non-descent  from  the  abdominal  cavity,  retention  in  the 
inguinal  canal,  or  entire  want  of  development.  The  vas  deferens  or  epi- 
didymis may  be  absent  or  unconnected  with  the  gland. 

Malposition  of  the  Testicle. 

This  is  not  a  very  uncommon  anomaly.  One  or  both  may  be  aifected, 
but  more  usually  only  one,  and  that  one  the  left.  The  organ  may  be  re- 
tained (1)  in  the  abdominal  cavity,  (2)  the  inguinal  canal,  (3)  situated 
just  without  the  external  abdominal  ring,  or,  very  rarely,  (4)  in  the  peri- 
neum. 

In  all  positions  external  to  the  internal  ring,  the  gland  is  excessively 
liable  to  injury  and  inflammation  because  of  its  fixed  and  constricted  posi- 
tion, and,  as  a  rule,  is  imperfectly  developed  or  rudimentary. 

Causes. — The  causes  of  malposition  are :  narrowing  of  the  inguinal  rings 
or  of  the  canal,  premature  enlargement  of  the  organ,  adhesions  acquired 
in  the  abdomen  or  in  the  descent,  a  short  spermatic  cord,  and,  possibly, 
paralysis  of  the  gubernaculum  testis. 

Treatment. — No  treatment  is  applicable  to  testes  remaining  in  the 
abdominal  cavity.  When  otherwise  situated  attempts  may  be  made  to 
manipulate  the  organ  into  the  scrotum  or  to  suture  it  to  the  bottom 
thereof,  and  afterward  apply  a  truss  to  the  external  ring  to  prevent  its 
return  or  the  development  of  hernia.  If  the  gland  becomes  subject  to 
inflammation  or  is  otherwise  troublesome,  it  should  be  promptly  excised. 

Epididymitis. 

Epididymitis,  or  inflammation  of  the  epididymis,  is  the  most  common 
inflammatory  affection  of  the  testicle.  It  may  be  associated  with  orchitis, 
but  much  more  usually  is  independent.  It  may  be  acute  or  chronic, 
single  or  double. 

Causes. — Almost  all  cases  are  caused  by  septic  (gonorrhoeal,  etc.) 
material  travelling  along  the  vas  deferens  from  the  deep  urethra ;  but 
may  follow  instrumentation  or  injury,  or  arise  in  the  course  of  syphilis. 

Symptoms. — Rather  suddenly  and  with  marked  febrile  reaction  the 
epididymis  becomes  swollen,  painful,  and  exquisitely  sensitive  to  pressure. 
The  pain  is  of  a  sickening,  dragging,  throbbing  variety,  and  is  in  part 
referred  to  the  loins  and  inguinal  regions  or  thighs.  The  spermatic  cord 
is  likewise  enlarged  and  sensitive.  The  tumefaction  is  confined  to  that 
portion  of  the  testicle  corresponding  to  the  position  and  outlines  of  the 
epididymis,  which  becomes  hard,  tense,  and  heavy.  Hydrocele  may 
complicate  the  affection  as  well  as  its  diagnosis.     If  gonorrhcea  has  been 


716  THE    REPRODUCTIVE    ORGANS. 

the  cause,  urethral   discliarge  greatly  diminishes  or  disappears  tempo- 
rarily.    Abscess  is  an  unusual  termination. 

In  the  course  of  a  week  acute  symptoms  begin  to  subside,  l)ut  swelling, 
some  pain,  and  tenderness  remain  for  weeks,  months,  or  perhaps  pernia- 
nentl}'.  When  all  symptoms  have  disappeared  the  testicle  will  usually 
remain  decreased  in  size  and  sterile.  Double  epididymitis  may  produce 
complete  sterility. 

Treatment. — The  treatment  sh  )uld  consist  of  rest  in  bed,  elevation  of 
and  cold  affusions  to  the  scrotum,  leeches  along  the  spermatic  cord,  laxa- 
tives, restricted  diet,  and  o])ium  and 
Fig.  450.  belladonna  suppositories  for    pain. 

^  /-'^^  /■-  ^  Abscesses,  when  they  arise,  should 

f '^      t\^^->'  '-'^^'r'^d'''--.       ^^  promptly  opened.' 

To  eradicate  the  swelling  and 
hardness  of  the  organ,  which 
usually  persist  for  a  long  time  after 
the  disappearance  of  acute  symp- 
toms, strapping  of  the  parts  by 
strips  of  adhesive  plaster  or  a  long, 
Method  of  strapping  testicle.    (Smith.)        thin  rubber  bandage  applied  to  the 

scrotum  should  be  resorted  to,  and 
the  whole  supported  by  a  snugly-fitting  suspensory  bag. 


Orchitis. 

Inflammation  of  the  secreting  or  gland  substance  of  the  testicle.  This 
is  a  less  frequent  affection  than  epididymitis,  but  often  exists  in  conjunc- 
tion therewith.     One  or  both  testes  may  be  attacked. 

Causes. — The  causes,  outside  of  those  of  epididymitis,  are  almost  lim- 
ited to  injuries  and  metastasis  in  parotitis  and  pyemia. 

Symptoms. — The  symptoms  are  mainly  those  of  inflammation  of  the 
epididymis,  but  the  organ  is  heavier  and  assumes  a  more  oval  outline, 
corresponding  to  the  shape  of  the  gland.  The  pain  is  more  nauseating 
and  there  is  an  almost  intolerable  sense  of  dragging  weight.  Later  the 
sci'otum  becomes  tense  and  swollen,  and  not  infrequently  abscess  forms. 
The  acute  stage  likewise  lasts  about  a  week,  but  if  suppuration  does  not 
occur,  the  gland  then  speedily  resolves  to  a  normal  condition.  Sterility  is 
an  even  more  common  sequence  here  than  in  epididymitis. 

Treatment. — The  treatment  likewise  corresponds  with  that  of  the 
epididymal  inflammation.  When  abscess  forms  and  opens  or  is  incised 
the  mass  of  glandular  structure  is  apt  to  slough  out  as  a  whole.  Chronic 
inflammation,  or  continued  purulent  discharge  from  the  testicle,  may 
demand  its  ablation. 

Tuberculosis  of  the  lesticle. 

Tuberculosis  of  the  testicle  affects  generally  but  one  side,  and  in  those 
of  tuberculous  tendency,  or  as  a  complication  of  tuberculosis  elsewhere  in 
the  body  ;  beginning  as  a  rule  in  the  epididymis,  and  subsequently  involv- 
ing the  gland  proper. 

Symptoms. — The  epididymis  becomes  tumefied,  but  without  marked 
pain  or  tenderness,  and  later  the  testicle  likewise  enlarges,  suppuration 
with  abscess  formation  supervenes  and  constitutional  disturbance  may  or 


THE    TESTICLE,  71'i 

may  not  arise.  Hydrocele  may  complicate.  The  gland  may  slough  away 
after  opening  of  the  abscess,  but  in  any  case  obstinate  fistula  with  puru- 
lent discharge  are  apt  to  follow  the  evacuation  of  these  abscesses.  It  is 
often  absolutely  impossible  to  diagnose  tuberculosis,  even  at  late  stages, 
from  tumors  of  the  testicle  before  incision  is  made. 

Treatment. — Excision  of  the  afiected  organ  is  alone  admissible. 

Tumors  of  the  Testicle. 

Sarcoma  is  the  most  common  primary  tumor  of  the  testicle  met  with, 
but  carcinoma,  adenoma,  chondroma,  dermoid  and  other  cysts,  and  tera- 
toma are  of  rare  occurrence  in  this  locality. 

Sarcoma  is  usually  small  in  size  and  of  the  round-celled  variety,  but  if 
large  more  usually  is  cystic  and  of  spindle-cell  construction. 

Carcinoma  occurs  only  in  those  advanced  in  life  and  is  always  encepha- 
loid  in  type. 

Symptoms. — The  symptoms  of  these  two  classes  of  tumors  are  almost 
identical.  The  organ  becomes  tense,  firm,  heavy,  globose,  does  not  expand 
upon  coughing,  is  flat  upon  percussion,  and  is  opaque  to  the  light  test. 
The  cord  may  also  be  more  or  less  involved.  Sarcoma  in  late  stages  often 
assumes  huge  proportions  and  remains  smooth  and  regular  in  contour. 
The  skin  may  slough  over  portions  of  the  growth,  but  necrosis  is  limited 
to  the  integument.  On  the  other  hand,  carcinoma  becomes  nodular  in 
late  stages  and  tends  to  involve  every  adjacent  structure,  while  sloughing 
extends  deeply  into  the  interior  of  the  growth.  Excision  of  the  testicle 
and  growth  should  be  performed  at  as  early  a  stage  as  possible.  Meta- 
stasis and  recurrence  in  the  cord  or  elsewhere  are  usual. 

Injuries  of  the  Testicle. 

Severe  contusions  and  wounds  of  the  testicle  are  accompanied  by  an 
amount  of  shock  totally  disproportionate  to  the  injury,  owing  to  the  great 
sympathetic  distribution  to  the  gland.  Profound  syncope  or  even  death 
may  be  caused  thereby.  Inflammation  and  abscesses  commonly  follow 
these  injuries. 

Excision  of  the  Testicle  (  Castration). 

The  parts  having  been  properly  cleansed  and  shaved,  a  vertical  incision 
is  made  from  end  to  end  through  the  antero-lateral  portion  of  the  scrotum 
until  testicle  and  cord  are  equally  exposed  in  the  wound.  The  organ  is 
now  freed  from  its  cellular  attachments  and  lifted,  without  great  traction 
upon  the  cord,  from  the  wound.  A  double  strong  catgut  ligature  is  then 
passed  by  a  blunt  needle  through  the  middle  of  the  cord  well  above  the 
testicle  or  tumor,  and  each  half  firmly  tied  off".  The  cord  below  the  liga- 
ture is  now  severed  and  the  testicle  removed.  If  the  pedicle  is  very  large 
it  should  be  tied  ofl^  in  small  sections  in  similar  manner.  If  subsequent 
hemorrhage  is  feared  the  stump  may  be  transfixed  and  held  in  the  wound 
by  a  steel  pin.  The  wound  is  sutured,  drained,  and  dressed  in  the  usual 
manner. 

Spermatori'hcea. 

A  functional  disease  involving  involuntary  discharges  of  spermatic 
fluid  with  slight  or  no  sexual  pleasure  or  orgasm.     It  must  not  be  con- 


718  THE    REPRODUCTIVE    ORGANS. 

founded  with  mucous  or  gleety  discliarges  from  the  urethra,  with  the 
natural  nocturnal  emissions  of  continent  health,  or  those  produced  by 
strain,  as  at  stool,  forcing  semen  from  overcharged  seminal  vesicles.  The 
real  disease  is  dependent  usually  upon  excessive  irritability  of  the  ])ros- 
tatic  urethra,  brought  about  by  venereal  abuse,  and  is  generally  coincident 
with  a  peculiar  mental  condition,  either  as  cause  or  effect,  together  with 
great  excitability  of  and  lack  of  inhibitory  power  in  the  venereal  centres 
of  the  brain  and  cord  ;  or  it  may  be  but  a  symptom  of  grave  structural 
changes  in  the  central  nervous  system. 

Treatment. — Treatment  should  be  directed  to  improving  the  general, 
physical,  and  mental  condition,  and  to  removal  of  the  cause. 

The  Penis. 

Congenital  Abnormalities. 

The  penis  may  be  absent,  double,  or  tied  down  to  the  scrotum  by  a  web 
of  skin  or  broad  adhesion.  Also  portions  may  be  absent  or  imperfectly 
developed  and  produce,  more  especially  during  erection,  curvations  of 
various  degree  and  direction.  A  very  short  frenum  may  likewise  pro- 
duce curvation.  Phimosis  is  frequently  congenital.  Acquired  deformities 
result  usualh'  from  sloughing,  incident  to  injuries  and  chancroidal  sores. 
Many  cases  of  each  variety  above  mentioned  are  capable  of  great  im- 
provement or  entire  cure  by  plastic  operations,  perhaps  combined  with 
excision  of  portions  of  the  organ. 

Phiynosis. 

Elongation  of  the  prepuce  with  contraction  of  its  orifice.  It  may  be 
congenital  or  acquired.  In  either  case,  but  especially  the  former,  the 
mucous  layer  of  the  prepuce  is  apt  to  be  more  or  less  ad- 
Fui.  451.  herent  to  the  glans  penis,  while  smegma  collects  and  de- 
composes around  the  corona,  producing  great  irritation. 
Not  uncommonly  these  sebaceous  concretions  calcify. 
Acquired  phimosis  generally  results  from  irritation,  pro- 
duced by  long-continued  uncleanliness,  cicatricial  contrac- 
tion of  the  preputial  orifice  or  gonorrhoea.  A  very  acute 
form  of  phimosis  often  has  origin  in  the  swelling,  retained 
secretions,  and  inflammation  incident  to  acute  gonorrhoea 
or  chancroids  beneath  the  prepuce. 

The  condition  predisposes  markedly  to  the  acquisition 
of  venereal  disorders;    may  give  rise  to   obstruction   to 
micturition,  cystitis,  or  to  reflex  spastic  palsy,  general  or 
Phimosis.         local  spasms.     As  result  of  straining  to  pass  water,  pro- 
(Smith.)  lapse  of  the  rectum  or   hernia  may  occur.     In  adult  life 

phimosis  may  interfere  with  copulation  or  reproduction. 
Treatment. — In  every  case  Avhere  difficulty  is  experienced  in  retract- 
ing the  prepuce,  or  where  adhesions  or  irritative  collections  of  smegma 
are  present,  operation  for  its  permanent  relief  should  be  urged.  For  this 
purpose  either  of  two  methods  may  be  resorted  to:  1.  Slitting  up  the  pre- 
puce; or,  2.  Circumcision. 

1.  Insert  a  small  grooved  director  into  the  preputial  orifice  and  carry  its 
point  gently  over  the  anterior  surface  of  the  glans  exactly  in  the  median 


THE    PENIS. 


719 


line  to  the  corona.  Now  Avith  knife  or  scissors  slit  up  the  prepuce  upon  the 
director,  as  a  guide,  to  an  equal  distance.  More  frequently  than  not  the 
mucous  layer  of  the  prepuce  will  be  pushed  ahead  of  the  director  and 
only  the  cuticular  layer  will  be  cut.  If  so,  then  reinsert  the  instrument 
beneath  the  undivided  portion  and  divide  it  likewise.  When  adherent  to 
the  glans  this  flap  is  torn  free  to  the  corona  on  all  sides  with  the  fingers. 
Now  its  corners  are  trimmed  round  and  the  two  layers  are  sutured 
together  at  a  few^  points  with  catgut.  A  little  iodoform  is  rubbed  into 
the  wound  and  an  antiseptic  dressing  with  a  button-hole  cut  in  it  is  slipped 
over  the  glans.  A  large  wad  of  cotton  is  placed  over  the  whole,  retained 
by  a  diaper  or  T-bandage,  and  changed  as  often  as  necessary.  If  the 
penis  is  large  the  dressing  may  be  applied  around  it  and  retained  by  a 
narrow  bandage. 

2.  Circumcision. — Without  pulling  the  foreskin  down,  grasp  it  at  the 
middle  of  the  glans  in  an  antero-posterior  obliquely  downward  and  for- 
ward direction  with  a  pair  of  catch  forceps.  Fasten  them,  and  with  a 
short  knife  or  scissors  cut  through  the  grasped  prepuce  immediately  in 
front  of  the  forceps.  This  will  usually  remove  a  circle  of  integument,  but 
leave  the  mucous  layer  embracing  the  glans  tightly.  This  latter  is 
divided  upon  a  director,  as  above  described,  and  the  two  flaps  thereby 
formed  are  sutured  at  several  points  to  the  skin  wound.     Any  bleeding 


Fig.  452. 


Fig.  45.3. 


Phimosis  forceps. 


Circumcision.     (Eeichsex.) 


should  be  con-trolled  by  sutui-e  or  ligature,  especially  when  from  the 
artery  of  the  frenum.  Dress  as  above  described,  Subsequent  hemor- 
rhage— which  should  be  examined  for  at  frequent  intervals  during  the 
first  twenty-four  hours — must  be  controlled  by  opening  the  wound  and 
ligating  the  bleeding  point. 

Paraphimosis. 

Paraphimosis  denotes  that  condition  which  exists  when  a  tight  fore- 
skin becomes  retracted  behind  the  corona  and  there  caught.     Mild  de- 


720 


THE    REPRODUCTIVE    ORGANS. 


grees,  and  all  when  early  dealt  with,  seldom  result  in  serious  eonsecjuence, 
but  when  the  condition  has  lasted  some  time  great  swelling,  inflammation, 
or  even  gangrene,  with  severe  constitutional  involvement,  may  take  place. 
Trkatment. — Paraphimosis  can,  as  a  rule,  easily  be  reduced  by  grasp- 
ing and  making  traction  upon  the  penis  with  one  hand,  while  the  fingers 

of  the  other  make  steady  pressure  upon 
the  glans.  Or,  the  glans  may  be  tightly 
wound  about  (as  a  top)  with  a  cord, 
which,  when  all  cedema  has  been  re- 
duced, is  (juickly  taken  away  and  ^the 


Fui.  455. 


Fig.  454. 


Reduction  of  paraphimosis. 
(Phillips.^ 


Dividing  the  constricting  band  in  paraphimosis. 
(Bryant.) 


swollen  foreskin  pulled  over  the  glans.  Again,  when  these  measures 
fail,  or  great  swelling  or  inflammation  is  present,  the  band  of  constric- 
tion should  be  divided  in  the  median  line  in  front.  This  incision  will 
always  allow  the  prepuce  to  be  brought  down.  No  sutures  are  retjuired. 
Recurring  paraphimosis  should  be  treated  by  circumcision. 

Inflammation  of  the  Peni?. 

Inflammation  of  the  penis  may  arise  from  injury  or  extension  from  a 
virulent  ulcer  or  contiguous  parts.  Either  the  body  of  the  organ  or  its 
integument  may  be  aflfected.  Either  variety  may  progress  to  purulent 
formation,  gangrene,  or  extend  to  the  scrotum,  pubis,  and  abdominal 
wall.  Permanent  induration,  or  calcification  of  portions  of  or  the  entire 
penis,  may  result  from  chronic  inflammation.  Cases  of  inflammation  of 
the  organ  with  great  swelling,  more  particularly  in  children  and  where 
no  palpable  cause  exists,  should  be  carefully  examined  for  strings  or  bands 
placed  around  the  organ  for  mischief,  and  which  subsequently  have  be- 
come buried  in  the  swollen  tissues. 


Balanitis 

Inflammation  of  the  mucous  or  inner  surface  of  the  prepuce.  Retained 
normal  or  pathological  secretions  (as  gonorrhceal  pns)  are  the  usual  cause. 
The  affection  almost  always  coexists  with  posthitis  (then  termed  balano- 
posthitis),  an  inflammation  of  the  epithelial  covering  of  the  glans  penis 
arisins:  from  like  causes. 


THE    PENIS.  721 

Treatment. — The  treatment  consists  of  cleanliness  and,  so  far  as  pos- 
sible, removal  of  the  cause.  Astringent  drying  powders  are  of  value. 
Circumcision  may  occasionally  be  demanded. 

Herpes. 

Herpes  upon  the  glans  and  [around  the  preputial  margin  are  of  fre- 
quent occurrence  and  of  great  annoyance  because  of  the  intense  itching. 
They  resemble  herpetic  eruptions  elsewhere  and  are  caused  usually  by 
decomposing  or  irritative  secretions. 

Treatmeiit. — Scrupulous  cleanliness,  drying  powders,  zinc  ointment,  or, 
for  very  persistent  cases,  circumcision. 

Chancre  and  Chancroid  of  the  Penis. 

Chancre  and  chancroid  are  much  more  commonly  found  situated  upon 
the  glans  penis  and  prepuce  than  anywhere  else  upon  the  body.  The  diag- 
nosis and  treatment  of  chancre  have  been  already  described  (see  Syphilis). 

Chancroid  (soft  or  non  infecting  chancre)  occurs  most  frequently  at  the 
junction  of  the  glans  and  prepuce  upon  the  corona  glandis.  There  may 
be  one,  two,  or  more  present.  These  sores  present  the  following  charac- 
teristics :  They  begin  within  a  few  days  or  even  hours  after  the  deposit  of 
the  poison  as  a  pustule  or  irritated  abrasion  ;  several  may  develop  succes- 
sively and  others  are  almost  certain  to  develop  at  points  of  contact  with 
healthy  skin  or  mucous  membrane.  Pus  from  one  sore  invariably  pro- 
duces a  similar  sore  when  inoculated  elsewhere.  When  fully  developed 
chancroids  appear  as  one-fourth  to  one-half  inch  in  diameter,  vari-shaped, 
but  usually  ovoid,  rather  shallow  ulcers  with  clean-cut — punched  out  as 
it  were — edges,  having  a  depressed  floor  of  grayish  slough  from  which 
exudes  profuse  sanious  discharge.  They  are  surrounded  by  an  undefined 
zone  of  bright  red  inflammatory  infiltration,  and  upon  irritation  may 
greatly  increase  in  size  and  depth  and  cause  extensive  necrosis.  The 
inguinal  glands  always  early  become  inflamed  (bubo)  and  commonly 
suppurate.  The  nearer  the  sore  is  to  the  frenum,  the  more  marked  is  the 
glandular  involvement  of  the  corresponding  side.  Some  chancroids  heal 
kindly  without  great  gland  inflamnlation  in  the  course  of  a  week  or  two, 
while  others  take  on  more  decided  inflammatory  action,  increase  much  in 
size  and  cause  abscesses  in  one  or  both  groins,  Avhile  yet  others,  especially 
in  persons  debilitated  by  bad  food,  exposure,  or  debauchery,  become  ex- 
ceedingly severe  and  spread  most  extensively  and  destructively  (phage- 
denic ulceration  or  gangrene  sometimes  simply  termed  "phagedena."). 

The  diagnosis  between  chancre  and  chancroid  (see  p.  79)  cannot  be 
positively  made  except  by  the  appearance  or  non-appearance,  as  the  case 
may  be,  of  secondary  syphilitic  manifestations. 

Treatment. — Most  chancroids  heal  promptly  when  great  cleanliness 
is  combined  with  liberal  applications  of  iodoform  powder.  Indolent  sores 
should  be  stimulated  by  such  applications  as  strong  solutions  of  nitrate 
of  silver ;  spreading  sores  by  nitric  acid ;  and  phagedena  by  nitric  acid, 
bromine,  or  actual  cautery  to  the  entire  aflected  area,  supplemented  by 
vigorous  constitutional  simulation  and  support.  Inflammation  of  the 
inguinal  glands  may  sometimes  be  aborted  by  leeches  or  blisters,  but 
when  suppuration  occurs  prompt  incision,  curetting  and  packing  should 
be  resorted  to.     Long-continued  discharge  from  sinuses  thereby  resulting, 

46 


722  THE    REPRODUCTIVE    ORGANS. 

or  repeated  formation  of  abscesses,  should  he  met  hy  excision  of  all  the 
atiected  glands. 

A  tight  prepuce  interfering  with  treatment,  or  causing  retention  of  se- 
cretions, should  at  once  be  slit  up,  and  allowed  to  heal  by  granulation. 

Ti'MORs  01'  THK  Penis. 

Papilloma. 

Papillomata  (warts)  are  very  common  about  the  glans  and  prepuce, 
and  arc  almost  always  of  syphilitic  origin.  The  corona  and  prej)utial 
margin  are  the  most  usual  points  of  development.  The  parts  should  be 
kept  clean  and  dry  by  application  of  powders  of  calomel  and  zinc  oxide 
(1  to  '2)  or  tannic  acid.  This  failing,  they  may  be  painted  with  nitric  or 
chromic  acid,  or,  best  of  all,  snipped  off  with  scissors,  and  the  base  or 
pedicle  touched  with  nitric  acid,  or,  should  free  bleeding  occur,  with  the 
cautery. 

Carcinoma. 

Carcinoma,  usually  of  the  epitheliomatous  tyi)e,  may  attack  the  penis. 
It  may  at  first  involve  the  glans  or  prepuce  alone,  but  sooner  or  later  all 
portions  of  the  ])enis  are  involved,  and  later,  the  inguinal  glands  and  tis- 
sues of  the  scrotum  and  pubis  become  likewise  diseased.  It  can  be  mis- 
taken in  the  early  stages  for  manifestations  of  syphilis,  but   .-should  the 

Fifi.  45(i. 


Epithelioma  ol'  Penis. 


process  not  disappear  under  anti-syphilitic  treatment  the  former  diagnosis 
is  maintained.  If  glandular  involvement  has  not  taken  place,  prognosis 
is  fair,  otherwise  gloomy.  Ablation  of  the  penis  well  behind  the  affected 
area,  together  with  removal  of  all  enlarged  glands  in  the  groin  and 
lymphatics  leading  thereto,  is  the  only  plan  of  treatment  offering  any 
chance  of  success. 


THE    VULVA.  723 


Injuries  of  the  Penis. 

Contusions  and  integumentary  wounds  call  for  no  special  description. 
Rupture  of  the  sheaths  of  one  or  both  corpora  cavernosa  ("  fracture  of 
the  penis"),  occasionally  takes  place  as  result  of  violence  to  the  organ 
while  it  is  in  the  erect  state,  and  constitutes  a  very  grave  accident.  At 
once  there  is  a  subsidence  of  the  erection,  great  shock  and  pain,  nausea, 
and  extravasation  of  blood  into  the  penile  tissues,  and  the  whole  organ 
becomes  greatly  hypertrophied  thereby.  The  blood  may  find  its  way  into 
the  scrotum  or  upon  the  abdomen. 

Suppuration  and  gangrene  are  apt  to  occur — more  particularly  when 
urine  is  also  at  the  time,  or  subsequently,  extravasated  into  the  tissues — 
unless  free  incisions  are  at  once  made  in  all  directions  of  extravasation. 
When  recovery  takes  place,  traumatic  stricture  and  an  indurated  deformed 
organ,  unfit  for  copulation,  usually  results. 

Excision  of  the  Penis. 

The  parts  having  been  cleansed  and  shaved  in  the  usual  manner,  and 
an  umbrella  ring  or  other  tourniquet  applied  to  the  root  of  the  organ,  the 
skin  is  drawn  well  forward,  and  a  circular  integumentary  incision  made 
well  above  the  diseased  area. 

The  corpora  cavernosa  are  then  divided  at  the  same  level,  and  the 
spongy  body  at  a  point  half  an  inch  nearer  the  glans.  The  latter  portion 
is  now  split  for  a  distance  of  half  an  inch  longitudinally,  and  each  half 
of  the  urethra  sutured  laterally  to  the  skin  of  the  corresponding  side.  All 
hemorrhage  is  stopped,  a  catheter  introduced,  and  an  antiseptic  dressing 
applied.  The  catheter  should  be  taken  out  on  the  second  day,  and  natural 
micturition  may  be  permitted  from  that  time  on.  If  the  stump  is  very 
short  the  patient  must  be  provided  subsequently  with  a  short  canula  or 
catheter,  through  which  to  direct  the  stream  of  urine. 

The  Vulva. 

Adhesion. 

Adhesion  of  the  vulvar  lips  may  be  recognized  upon  separating  the 
labial  folds,  when  no  introitus  vagina  is  visible,  and  a  thin  bluish  mem- 
brane connects  the  labia. 

Treatment. — After  puncture  with  a  knife  the  membrane  may  readily 
be  broken  down  with  a  finger  introduced  through  the  incision.  Any 
bleeding  vessels  should  be  ligated  and  the  parts  kept  well  separated  by  a 
plug  for  twenty -four  hours. 

Varix. 

Varix  of  the  pudendal  veins  usually  exists  in  conjunction  with  vari- 
cosity of  the  leg  veins,  but  may  occur  independently.  The  veins  sometimes 
attain  great  size,  but  as  a  rule  cause  little  distress  or  danger,  unless  they 
become  ruptured  either  spontaneously  or  by  traumata,  as  in  childbirth. 
Subcutaneous  rupture  gives  rise  to  hematocele,  external  rupture  to  vio- 
lent bleedinsc. 


724  THE    REPRODUCTIVE    ORGANS. 

Treatment. — When  laceratiou  takes  place,  cold  compression  should 
be  applied  to  mild  cases,  ligation  to  more  serious  ones. 

Henmtoyna. 

Infiltration  of  the  i)udondal  tissues  with  blood.  This  condition  may 
result  from  rupture  of  varicose  veins  or  from  subcutaneous  injury,  and 
usually  the  tumor  attains  the  size  of  an  orange.  The  mass  may  be  ab- 
sorbed, become  a  blood  cyst,  or  suppurate.  Inflammation  originating 
therein  may  travel  beyond  the  vulvar  limits,  even  into  the  deep  ))elvis. 

Treatment. — Cold  and  moderate  pressure  at  first;  later,  if  it  persist, 
incision  and  drainage — the  latter  always  upon  first  signs  of  inflammation 
or  abscess. 

Vulvitis. 

Inflammation  of  the  vulva  is  particularly  apt  to  arise  in  the  labia, 
from  such  causes  as  contusions,  wounds,  uncleanliness,  foul  vaginal  dis- 
charges, or  the  presence  of  parasites  (as  oxyuris  vermiformisj,  and  as  a 
complication  in  low  fevers  or  general  depraved  conditions.  It  may  be  acute, 
chronic,  or  limited  to  the  vulvar  follicles.  In  certain  acute  cases  abscess, 
sloughing,  or  spreading  gangrene  (noma  vulvae)  may  develop.  The  last 
mentioned  variety  much  resembles  cancrum  oris,  is  likewise  almost  con- 
fined to  strumous  children,  and  in  this  situation  becomes  equally,  if  not 
more  dangerous. 

Treatment. — Cleanliness,  vaginal  douching,  and  hot  moist  applica- 
tions will  alone  be  required  for  most  cases.  Abscesses  should  be  opened 
at  an  early  stage,  curetted,  and  packed.  Spreading  gangrene  should  bs 
met  with  liberal  stimulation,  quinine,  and  locally  with  free  incisions  and 
applications  of  bromine  or  actual  cautery. 

Follicular  Vtdvitis. 

Inflammation  of  the  subaceous  and  hair  glands  of  the  labia  and  genito- 
crural  folds.  It  is  quite  common  during  pregnancy  and  in  the  unclean. 
The  parts  are  oedematous,  hot,  and  subject  to  an  intense  burning  itch. 
The  connective  tissues  are  infiltrated  and  the  follicles  stand  out  hard,  red, 
and  vesicular  or  pustular. 

Treatment. — Cleanliness  and  applications  of  carbolic  or  lead-water 
and  laudanum  lotions.  Certain  cases  will  defy  all  treatment  until  preg- 
nancy ends. 

Inflammation  of  the  Vtdvo-vaginal  Glands. 

This  is  a  very  common  aflTection  of  this  region.  The  glands  lie  (me  on 
each  side  of  the  vaginal  outlet  in  the  base  of  the  lesser  labia  between  two 
layers  of  the  ischio-pubic  fascia,  and  communicate  with  the  surface  at 
the  vulvo-vaginal  junction  by  ducts  one-half  inch  in  length.  They  are 
particularly  liable  to  irritation  by  septic  discharges  travelling  up  these 
ducts.  One  or  both  may  be  involved,  and  abscess  is  the  usual  result. 
Diagnosis  is  made  by  palpating  the  bodies,  or  their  location,  between 
one  finger  in  the  vagina  and  another  upon  the  labium  minor:  a  hard, 
round,  or  fluctuating  tumor  is  felt  between  them. 

Treatment. — Hot  applications  until  pus  forms ;  then  early  incision 
through  the  labium. 


THE    VULVA.  725 


Destructive  Ulcers. 

The  vulva  is  liable  to  several  forms  of  destructive  and  perhaps  hyper- 
trophic ulceration.  These  embrace  lupus,- tuberculosis,  syphilis  and  epi- 
thelioma, all  of  which  are  most  prone  to  develop  in  cachectic,  unclean 
and  loose  women.  Differential  diagnosis  is  often  impossible  until  late 
stages. 

Treatment. — The  treatment  should  include,  according  to  the  nature 
of  the  process,  general  supportive  and  antisyphilitic  measures,  excisions 
and  cauterizations.  Excepting  in  those  yielding  promptly  to  anti-syph- 
ilitic treatment  the  prognosis  is  unfavorable. 

Chancre  and  Chancroid. 

Chancre  and  chancroid  frequently  develop  upon  the  vulva — especially 
in  its  deeper  folds  and  at  the  vulvo-vaginal  margin.  Chancroids  in  this 
region  are  prone  to  become  phagedenic  in  type. 

Elephantiasis. 

Elephantiasis  of  the  labia  and  clitoris  occurs  with  more  frequency  than 
do  analogous  troubles  in  the  male  organs.  Syphilis  would  appear  in  this 
case  to  be  the  usual  cause.  Diagnosis  and  treatment  do  not  differ  essen- 
tially from  those  in  the  male. 

Tumors. 

The  vulva  is  frequently  the  seat  of  syphilitic  condylomata  and  warts, 
papillomata,  lipoma,  fibroma  and  epithelioma,  all  of  which,  except  epi- 
theliomata,  have  a  marked  tendency  to  become  pediculated  and  ulcerated. 
Sarcoma  is  almost  unknown.  Cysts  of  the  vulva  almost  invariably  have 
their  origin  in  the  vulvo-vaginal  glands  or  from  hematomata. 

Injuries. 

Injuries  of  the  vulva,  excepting  lacerations  of  the  perineum,  call  for 
no  special  description. 

Laceration  oj  the  Perineum. 

This  occurs  as  an  accident  during  labor,  and  may  be  of  any  degree, 
from  mere  tearing  of  the  fourchette  to  rupture  down  to  or  even  through 
the  anal  sphincter  and  for  some  distance  up  the  rectum  through  the  recto- 
vaginal septum.  Tears  down  to  the  sphincter  give  rise  to  a  sense  of  weak- 
ness and  to  more  or  less  prolapse  of  the  pelvic  organs  from  lack  of  their 
natural  support,  while  lesions  involving  the  sphincter  accentuate  the 
above  symptoms  and  permit  incontinence  of  flatus  and  feces. 

Treatment. — Every  woman  should  be  examined  for  possible  lacera- 
tion immediately  subsequent  to  delivery.  If  such  is  found  to  exist  deep 
sutures  should  at  once  be  passed  from  side  to  side  in  a  transverse  direction  to 
the  tear.  Where  healing  of  the  laceration  has  already  taken  place  the  bowels 
should  be  well  cleared  out  by  a  purge  and  enemata.  The  patient  is  then 
placed  in  the  dorsal  position  upon  a  table  with  the  hips  at  the  edge.  _  The 
operator  sits  between  the  legs,  facing  the  parts.     Denudation  with  scissors 


'26 


THE    REPRODUCTIVE    ORGANS. 


or  knife  of  all  cicatrized  areas  and  especially  of  those  running  backward 
and  upward  on  either  side  of  the  vagina  is  now  made.  If  the  tear  runs 
into  the  rectum  the  edges  are  also  here  denuded  thoroughly,  and  the  re- 
tracted ends  of  the  sphincter  exposed.  Sutures  of  silkworm-gut  are  then 
passed  from  apex  to  base  of  the  vaginal  denudations,  there  brought  out, 
reinserted  and  brought  back  to  the  lower  edge  of  denudation  in  such 
manner  that  when  they  are  tied  the  edges  of  each  lateral  denudation  are 

Fig.  U7. 


Diagram  of  denudation  and  suturing  in  operating  for  perineal  laceration.    (Kelly.) 

brought  together  on  each  side  of  the  vagina  near  its  outlet.  These 
sutures  should  be  placed  four  to  an  inch,  embrace  no  skin,  and  be  tight- 
ened, shotted,  and  cut  off  short.  Then  are  inserted  two  or  three  stitches 
which  enter  skin  on  either  side  and  pa.ss  through  all  the  tissues  above 
the  sphincter,  and  emerge  through  skin  on  the  opposite  side;  but  if  the 
sphincter  is  torn,  two  or  more  sutures  should  include  integument  and  its 
denuded  ends.  The  latter  are  now  also  tightened  and  shotted.  A  tea- 
spoonful  of  iodoform  is  then  placed  in  the  vagina  and  rubbed  into  the 
wound.  No  dres-sing  is  required.  The  urine  must  be  drawn  by  catheter 
until  the  patient  can  voluntarily  pass  it.  The  bowels  should  be  kept 
fluid  after  the  first  day  by  saline  laxatives.  Sutures  may  be  removed  on 
or  after  the  tenth  day.  If  irritation  or  discharges  develop,  vaginal 
douching   should  be  employed. 


The  Vagina. 

Congenital  Abnormalities. 

Congenital  abnormalities  of  the  vagina  are  chiefly  important  in  the 
interference  which  they  may  offer  to  the  escape  of  menstrual  discharges, 
to  childbirth,  and  to  sexual  congress.  They  comprise:  absence  of  or  rudi- 
mentary or  double  vagina,  atresia,  stricture,  and  imperforate  or  unusually 


THE    VAGINA.  727 

well-developed  hymen.  The  canal  may  also  terminate  anomalously  in 
the  bladder  or  rectum.  Stricture  may  also  be  acquired  as  result  of  cica- 
trization of  ulcers  or  wounds,,  or  by  organization  and  contraction  of 
inflammatory  deposits. 

Treatment. — Imperforate  or  persistent  hymen  can  readily  be  relieved 
by  making  a  small  incision  into  the  membrane  and  tearing  it  up  to  the 
vaginal  wall.  Hemorrhage  must  then  be  controlled  and  a  large  plug 
of  dressing  kept  in  for  a  day  or  two.  Stricture — -whether  congenital 
or  acquired — may  be  treated  by  dilatation,  perhaps  combined  with  incis- 
ions, but  these  measures  must  be  guided  by  the  greatest  prudence  and 
caution  to  prevent  injury  to  the  peritoneum,  rectum,  and  bladder. 

Retained  Menses. 

Retained  menses  may  be  diagnosed  when  at  the  usual  period  of  jDuberty 
they  do  not  appear,  while  each  month  there  recur  attacks  of  pelvic  pain 
accompanied  by  severe  constitutional  disturbance,  and,  upon  inspection, 
a  tense,  bulging,  fluctuating  tumor  -presents  at  the  vaginal  orifice,  and  may 
extend  even  largely  into  the  pelvis  and  abdomen.  When  this  condition 
is  not  promptly  relieved  a  fatal  result  may  ensue  from  peritonitis  incident 
to  rupture  of  the  accumulation  into  the  abdominal  cavity,  or  from  suppu- 
ration in  the  vaginal  walls  or  neighborhood. 

Vaginitis. 

Vaginitis,  either  simple  or  specific  (gonorrhoeal),  is  very  common.  The 
latter  variety  corresponds  to  infectious  urethritis  in  the  male. 

Treatment. — The  treatment  of  both  forms  consists  of  cleanliness  and 
frequent  removal  of  discharges  by  copious  injections  of  hot  antiseptic 
fluids  and,  later,  of  astringent  solutions.  Vaginitis  is  generally  quite 
amenable  to  treatment  and  is  rarely  followed  or  accompanied  by  compli- 
cations other  than  subsequent  disease  of  the  uterus  (metritis)  and  its 
appendages  (salpingitis). 

Chancre  and  Chancroid. 

Chancre  and  chancroid  find  their  most  common  site  in  the  female  in 
the  vagina  near  its  orifice,  and  are  here  liable  to  produce  the  same  compli- 
cations as  when  elsewhere  situated. 

Fistulce. 

Fistul^e  between  the  vagina  and  bladder  (vesico-vaginal),  urethra 
(urethro-vaginal),  or  rectum  (recto-vaginal)  are  frequently  met  with. 
They  usually  result  from  sloughing  following  difiicult  childbirth  or  from 
venereal  and  other  ulcerations,  although  wounds,  either  surgical  or  acci- 
dental, may  give  them  origin. 

Owing  to  the  consequent  incontinence  of  urine  or  flatus  and  feces  and 
the  excessive  irritation  incident  thereto,  the  patient's  plight  is  indeed  a 
miserable  one. 

Treatment. — Very  small  fistulae  may  sometimes  be  induced  to  close 
by  repeated  stimulation  of  their  edges  with  a  hot  wire  or  caustic,  but 
persistent  or  larger  openings  must  be  dealt  with  by  a  plastic  operation. 


728 


THE    REPRODUCTIVE    ORGANS. 


Fig.  45m. 


Oi'ERATiox. — The    ]>atieut's  bowels  having  been    cleared   out   she  is 
placed  in  the  lithotomy  position  for  bladder,  or  the  knee-chest  attitude  for 

rectal  openings,  and  the  vagina,  if  necessary, 
is  well  exposed  by  a  Sims's  speculum.  The 
mucous  membrane  is  then  carefully  dissected 
for  one-third  of  an  inch  in  all  directions  about 
the  fistulous  opening  in  the  vagina  with  knife 
or  scisso)*s.  Now  transverse  sutures  of  silk,  silk- 
uorni-gut,  or  wire  are  inserted,  six  to  the  inch, 
in  the  following  manner:  The  needle  is  en- 
tered one-fifth  of  an  inch  beyond  the  denuded 
area,  carried  through  the  muscular  wall  of  the 
vagina  to  the  fistula  margin  ;  it  is  then  brought 
out  and  reinserted  into  the  muscular  coat  upon 
the  opposite  side  of  the  fistula,  carried  through 
it  and  brought  out  likewise  one-fifth  of  an  inch 
beyond  the  denudation.  The  sutures  thus  in- 
serted are  then  tightened  and  fastened  by  tying, 
shotting,  or  twisting,  according  to  the  suture 
material  employed.  If  a  vesico-vaginal  fistula, 
a  catheter  should,  subsequent  to  the  operation, 
be  passed  at  frequent  intervals  or  left  in  with  a 
tube  attached  running  over  the  side  of  the  bed 
into  a  suitable  receptacle.  In  any  case  the 
bowels  should  be  moved  by  a  saline  purge  daily  after  the  first  twenty -four 
hours.  If  the  fistula  is  very  extensive  it  may  be  necessary  to  turn  flaps 
from  the  vairinal  wall  into  it  and  there  suture  them  in  similar  manner. 


Sinis's  speculum. 


Tumors  of  the  vagina  are  rare, 
fibromatous,  or  carcinomatous. 


Tumors. 

They  may  be  cystic,  papillomatous, 


Foreign  Bodies. 

Foreign  bodies  may,  by  accident,  or  lascivious,  or  other  intent,  find 
their  way  into  the  vagina.  Xo  definite  rules  can  be  laid  down  for  their 
extraction. 

Wo  u)  ids. 


Wounds  of  the  vagina  usually  occur  during  childbirth  or  coitus,  but 
may  also  be  caused  by  accidental,  surgical,  or  criminal  means.  They  are 
extremely  dangerous  when  the  peritoneal  cavity  is  entered. 

Treatment. — The  vuluerating  body  must  be  removed  if  still  present, 
the  vagina  thoroughly  cleansed,  drained,  and  its  orifice  well  protected  by 
antiseptic  dressings,  which  should  be  renewed  each  time  that  urination 
occurs.  Peritoneal  infiammatory  involvement  will  demand  immediate 
abdominal  section,  irrigation,  and  drainage. 


CHAPTER    XXV. 

DEFOEMITIES.  OR  ORTHOPEDIC  SURGERY. 

Torticollis,  or  AVry-neck. 

Pathology. — Wry-neck  is  the  name  given  to  rotary  deviation  of  the 
head  caused  by  contraction  of  the  cervical  muscles.  The  muscular  spasm 
may  be  spastic  or  permanent ;  or  it  may  be  spasmodic,  and  then  is  usually 
accompanied  by  pain  whenever  the  spasm  producing  the  deformity  occurs. 
Hysterical  contraction  of  the  cervical  muscles  may  give  rise  to  hysterical 
torticollis.  A  similar  deviation  of  the  head  may  be  due  to  a  paralytic 
condition  of  one  of  the  groups  of  muscles,  and  also  to  cicatricial  con- 
traction of  the  skin  and  subcutaneous  structures  after  severe  burns  or 
other  destructive  injury.  The  sterno-mastoid  muscle  is  most  frequently 
the  seat  of  the  abnormal  contraction,  though  in  many  cases  the  trapezius 
muscle  and  the  scalene  muscles  may  be  involved  in  the  affection.  In 
some  instances  the  splenius  capitis  and  deep  rotators  of  the  head  seem 
to  be  the  displacing  agents.  The  affection  usually  involves  one  side  of 
the  neck,  but  cases  are  described  in  which  the  cervical  muscles  of  both 
sides  have  been  abnormally  contracted.  Congenital  torticollis  is  a  mal- 
formation or  is  due  to  injury  received  at  birth,  but  it  is  usually  the 
acc[uired  form  which  comes  under  the  surgeon's  notice. 

Torticollis  results  from  the  head  being  held  for  a  long  time  in  a  strained 
position,  as  in  inflammation  of  the  cervical  glands;  to  myositis  or  inflam- 
mation of  the  muscles  due  to  rheumatism,  gout,  or  other  causes ;  to  spasm 
of  the  muscle  induced,  probably,  by  lesions  of  the  central  nervous  system  ; 
to  muscular  spasm  the  result  of  injury,  and  reflex  irritation,  such  as 
intestinal  worms.  A  mild  form  of  torticollis  occurs  after  exposure  to 
cold,  and  is  called  by  the  laity  "  stiff"-neck." 

The  distortion  caused  by  caries  of  the  cervical  vertebrse  is  not  strictly 
torticollis. 

The  pathological  changes  which  occur  in  long-standing  cases  are  alter- 
ations of  the  shape  of  the  bones  and  ligaments,  and  degeneration  of  the 
contracted  muscles. 

Symptoms. — Wry-neck,  due  to  exposure  to  cold,  occurs  as  a  slight 
rigidity  of  the  cervical  muscles,  and  is  attended  with  pain  on  attempts 
at  motion.  Typical  torticollis,  due  to  contraction  of  the  sterno-mastoid 
muscle  of  one  side,  causes  the  head  to  rotate,  so  that  the  face  is  turned 
to  the  opposite  side,  and  the  chin  slightly  elevated.  The  muscle  which 
is  the  cause  of  the  defoymity  is  prominent  and  tense.  The  shoulder  on 
the  side  corresponding  to  the  affected  muscle  is  often  somewhat  elevated, 
and  a  slight  spinal  curvature  in  the  dorsal  region  is  not  uncommon.  The 
exact  character  of  the  displacement  varies  with  the  muscle  or  group  of 
muscles  involved. 

In  the  spastic  contraction  there  is  little  pain,  but  in  the  spasmodic 
form  the  head,  which  is  ordinarily  in  the  normal  position,  is  persistently 
and  violently  jerked  to  one  side,  while  severe  pain  is  felt  in  the  con- 


730  DEFORMITIES,    OR    ORTHOPEDIC    SURGERY. 

tracted  muscle  or  muscles  on  the  opposite  side  of  the  neck.  In  some 
cases  this  painful  spasm  and  rotary  displacement  of  the  head  occurs 
when  the  least  attempt  is  made  to  walk  or  to  use  the  arms.  In  other 
cases  the  spasmodic  contraction  occurs  at  fre<iuent  intervals  without 
reference  to  voluntary  movements. 

Treatment. — Mild  rheumatic  torticollis  is  cured  in  a  few  days  by  the 
application  of  heat,  by  means  of  bags  filled  with  hot  water,  sand,  or  salt, 
and  rubbing  with  stimulating  liniments,  aided  perhaps  by  hypodermic 
injections  of  atropia  (gr.  y^^  to  gr.   J,-). 

The  spastic  form  may  be  relieved  by  general  antesthesia,  and,  if  of 
hysterical  origin,  will  probably  not  return.  In  other  cases  a  collar-like 
apparatus  may  be  so  adjusted  i\s  to  prevent  a  reproduction  of  the  deform- 
ity when  the  patient  comes  out  of  the  anaesthetic  state.  Other  cases 
require  myotomy  or  division  of  the  displacing  muscle.  If  this  be  the 
sterno-mastoid  the  tenotome  should  be  introduced  beneath  the  muscle  at 
its  internal  edge,  just  above  the  clavicle,  and  as  much  of  the  muscle 
divided  as  .seems  necessary.  It  may  recpiire  two  punctures  with  the  teno- 
tome to  enable  the  surgeon  to  divide  both  the  sternal  and  clavicular 
heads  of  the  muscle  without  running  great  risk  of  injuring  the  deep 
vessels. 

After  the  muscle  has  been  divided,  the  head  should  be  turned  to  its 
normal  position  ;  but  it  is  said  to  be  well  to  return  it  to  the  abnormal 
position  and  leave  it  there  for  two  or  three  days  before  beginning  active 
manipulation  or  mechanical  treatment  to  bring  the  head  into  the  natural 
position. 

It  is  often  difficult,  in  the  more  complicated  cases,  to  decide  what  mus- 
cles are  responsible  for  the  deformity.  A  careful  study  of  the  character 
of  the  rotary  displacement  is  therefore  demanded.  It  is  especially  im- 
portant to  recollect  that  in  sterno-mastoid  contraction  the  head  is  turned 
to  the  side  opposite  to  that  of  the  affected  muscle.  Electricity  and  gym- 
nastics will  do  a  great  deal  here,  as  in  other  muscle  deformities.  Appa- 
ratus, whether  consisting  of  steel  springs  or  rubber  bands,  may  be  avail- 
able as  accessory  agents,  but  they  can  seldom  take  the  place  of  active 
and  passive  muscular  movements.  The  spasmodic  form  is  exceedingly 
intractable.  Myotomy  and  excision  and  stretching  of  the  spinal  accessory 
nerve  have  been  attempted  with  but  moderate  success.  This  nerve  is 
reached  by  an  incision  along  the  posterior  border  of  the  sterno-mastoid 
muscle,  after  which  the  edge  of  the  muscle  is  turned  up  and  the  nerve 
found  entering  its  lower  surface.  Excision  of  the  upper  cervical  nerves 
at  the  base  of  the  occiput  has  been  performed  in  at  least  one  case  where 
the  deep  rotators  were  supposed  to  be  at  fault.  The  fluid  extract  of 
gelsemium  in  very  large  doses  has  given  fair  results  in  some  cases. 
Preparations  of  this  drug  vary  greatly  in  strength,  and  minimum  doses 
should  be  used  at  the  beginning  of  the  treatment.  I  have,  however,  used 
as  much  as  thirteen  minims  every  two  hours  during  the  day  and  night 
for  several  weeks  and  found  satisfactory  results  from  it.  Massage  as  well 
as  passive  motion  should  be  used  as  adjuncts. 

Spixal  Curvatures. 

Patetology. — At  birth  there  are  no  curves  in  the  infant's  spine,  but 
as  the  child  assumes  the  sitting  or  erect  posture,  curves  which  are  recog- 
nized as  the  normal  vertebral  curves,  are  developed.  Weak  muscles, 
careless  postures,  the  prolonged  retention  of  positions  causing  abnormal 


SPINAL    CURVATURES.  731 

curves  of  the  spine  and  paralysis  of  special  groups  of  spinal  muscles  are 
causes  of  spinal  curvature.  Kickets  and  other  agencies  tending  to  inter- 
fere with  normal  development  of  the  growing  skeleton  are  sometimes 
causes  of  these  distortions  in  the  young. 

Angular  antero-posterior  curvature  of  the  vertebral  column  which  is 
due  to  caries  or  tuberculosis  of  the  vertebral  bodies,  belongs  to  and  is 
discussed  in  the  section  on  Joint  Diseases.  Its  jDathology  is  naturally 
distinct  from  the  spinal  deviations  now  under  consideration. 

The  rotary  lateral  deviation  of  the  spine,  to  which  the  name  scoliosis 
is  applied,  is  the  most  common  form  of  spinal  curvature.  Kyphosis,  the 
form  in  which  the  convexity  of  the  column  is  increased  in  a  posterior 
direction,  is  less  common ;  whereas  lordosis,  or  increased  convexity 
forward,  is  comparatively  frequent. 

These  deviations  of  the  spinal  column  are  due  to  relaxation  and  debility 
of  the  spinal  ligaments  and  muscles,  or  to  some  vicious  position  assumed 
while  at  work  or  at  rest  which  has  a  tendency  to  maintain  the  spine  in 
an  abnormal  position  for  a  considerable  portion  of  the  day.  As  a  conse- 
quence the  bones,  the  inter-vertebral  cartilages,  and  the  ligaments  become 
more  or  less  misshapen,  and  the  deviation  becomes  confirmed.  Congenital 
curves  of  the  spine  are  at  times  seen. 

Rotary  Lateral  Curvature,  or  Scoliosis. 

Rotary  lateral  curvature,  or  scoliosis,  is  particularly  common  in  young 
girls  about  puberty.  There  is  some  rotary  twisting  of  the  vertebral 
bodies  as  well  as  a  lateral  curving.  Ordinarily,  there  is  a  dorsal  curve, 
with  its  convexity  to  the  right  and  a  compensatory  curve  in  the  lumbar 
region  with  the  convexity  to  the  left.  There  may  be  four  curves  in  the 
length  of  the  spinal  column,  but  this  is  uncommon.  Sitting  at  school- 
desks  with  one  shoulder  unnaturally  elevated ;  carrying  an  infant  con- 
stantly on  one  side,  and  occupying  a  lolling  position  during  the  greater 
part  of  the  day,  will  tend  to  lateral  curvature  in  growing  girls  about  the 
menstrual  epoch.  Inequality  in  the  length  of  the  legs,  due  to  disease  of 
the  joints,  or  to  asymmetry  in  length,  will  equally  lead  to  lateral  curvature. 
Deformity  of  the  chest  from  pleuritis,  wearing  an  artificial  leg,  and  anky- 
losis from  hip  disease  may  be  similar  factors  in  spinal  distortion.  Rickets 
is  a  predisposing  cause,  as  well  as  of  osseous  deformities  in  other  parts 
of  the  skeleton. 

Projection  of  the  posterior  border  of  one  scapula  and  pain  in  the  cor- 
responding shoulder  and  the  back  may  be  the  first  symptoms  to  attract 
attention.  The  pain  may  be  scarcely  noticeable  during  the  day,  but  is 
felt  at  night,  or  when  lying  down  or  sitting.  The  winged  scapula,  as  this 
deformity  is  termed,  becomes  more  marked,  next  a  deviation  of  the  doi'sal 
spine  in  the  lateral  direction  is  observed,  and  soon  a  secondary  compen- 
satory curve  appears  in  the  lumbar  region.  Rubbing  the  skin  over  the 
spinous  processes  of  the  vertebrae  will  cause  red  spots  to  appear  over  these 
bony  prominences,  so  that  the  surgeon  can  readily  determine  the  absence 
or  extent  of  the  spinal  curvature.  The  spinous  processes,  however,  are 
in  reality  less  displaced  than  the  bodies  of  the  vertebrte  themselves,  which 
have  undergone  lateral  and  rotary  displacement.  The  viscera  may  be 
injured  and  compressed  by  the  deformed  skeleton,  and  some  anatomical 
change  in  the  position  of  the  vertebral  ligaments  may  arise  secondarily. 
If  the  deformity  is  great  a  deep  sulcus  occurs  between  the  lower  ribs  and 


732 


DEFORMITIES,    OR    ORTHOPEDIC    SURGERY. 


the  ilium  on  the  side  of  the  body  corresponding  with  the  convexity  of 
the  dorsal  curve.  The  ribs  and  ilium  may  actually  override,  and  burste 
may  be  formed  from  friction. 


Fig.  4.')9. 


Fin.  461', 


Fig.  459. — Vicious  position  during  writing.     (Reeves.) 

Fig.  460. — Right  lower  dorsal  and  left  lumbar  curvatures,  showing  unequal  height  oi 
shoulders  and  folding  of  the  soft  parts  in  the  left  ilio-costal  region.  The  left  hip  i^ 
higher  than  the  right.     (Reeves.) 

Kyphosis. 

Kyphoses,  or  round-back,  is  a  bending  of  a  part  or  whole  of  the  spine 
so  that  the  convexity  of  the  curve  is  backward,  giving  the  patient  the 
appearance  called  round-shouldered.  The  term  is  not  used  in  connection 
with  angular  curvature  due  to  tuberculosis  of  the  vertebrae.  Kyphosis 
occurs  in  children  and  in  old  persons,  and  is  commonly  in  the  upper 
portion  of  the  dorsal  region.  In  long-standing  cases  ossification  of  the  verte- 
bral joints,  so  that  the  bodies  become  ankylosed,  may  take  place.  Rickets 
and  faulty  positions  while  at  work,  or  at  rest,  may  be  the  cause  of  the 
deformity.  It  is  an  indication,  also,  of  the  increasing  debility  of  the 
tissues  which  occurs  in  the  aged.  Dyspnoea  and  other  visceral  symptoms 
may  be  induced  in  aggravated  cases. 


Lordosis. 

Lordosis,  or  hollow-back,  is  a  spinal  deviation  in  which  the  convexity 
of  the  curve  is  forward  ;  it  is  usually  found  in  the  lumbar  region,  due  to 
an  aggravation  of  the  normal  lumbar  curve.  Congenital  dislocation  of 
the  hips  gives  rise  to  lordosis.  Carrying  heavy  weights  on  the  head  is 
another  cause.     Pregnancy  and  abdominal  tumors  give  rise  to  temporary 


SPINAL    CURVATURES. 


733 


lordosis,  because  the  patient  must  bring  the  centre  of  gravity  further  back 
in  order  to  neutralize  the  weight  in  front  of  the  median  plane. 

Hollow-back,  whether  occurring  in  the  lumbar  region  or  the  cervical 
region,  is  characteristic.  When  the  patient  lies  upon  a  hard  mattress  the 
arching  of  the  spine  is  conspicuous.  There  may  be  compensatory  kyphosis, 
and  in  kyphosis  there  is  often  compensatory  lordosis.  Uterine  and  other 
visceral  trouble  may  occur  secondarily.    • 

Treatment. — The  prevention  of  spinal  deviation  is  exceedingly  im- 
portant in  young  subjects  presumably  liable  to  such  a  deformity.  Gym- 
nastic exercises  and  abstinence  from  positions,  whether  at  school  or  at 
Avork,  that  tend  to  exaggerate  the  normal  curves,  should  be  enforced. 
Even  slight  deviations  should  be  subjected  to  treatment,  because  they  may 
be  entirely  cured.  Absolute  restoration  of  the  outline  is  impossible  when 
the  bones  have  been  permanently  deformed  by  pressure,  or  when  ankylosis 
between  the  vertebral  bodies  has  occurred.  The  general  health  should 
be  improved  by  tonics  and  out-door  exercise,  and  by  abandonment  of  the 
injurious  habits  which  tend  to  confirm  the  deformily.  Gymnastic  exer- 
cises to  develop  weak  muscles  or  to  draw  the  bones  into  proper  position, 
should  be  instituted,  but  they  should  not  be  permitted  to  be  carried  far 
enough  to  fatigue  the  patient.  Swinging  by  the  hands  from  a  trapeze,  or 
from  the  top  of  a  door-way,  will  straighten  out  the  curves  by  the  traction 
exerted  by  the  lower  limbs.  The  use  of  dumb  bells  and  Indian  clubs, 
and  massage,  are  valuable  in  developing  the  muscles.  Propping  up  certain 
portions  of  the  trunk  while  lying  down,  or  the  use  of  a  spring,  such  as  is 
shown  in  the  diagram,  to  make  pressure  upon  the  distorted  spine,  will  be 
found  at  times  efficacious  in  relieving  the  deformity. 

The  motions  used  in  swimming  are  good  exercise  for  a  patient  with 
lateral  curvature,  and  they  may  be  performed  in  the  air  by  having  the 
patient  lie  upon  a  proper  support.  All  these  mechanical  measures  must 
be  continued  for  many  months  before  benefit  can  be  observed. 

Mechanical  support  is  valuable  as  an  adjuvant  in  developing  the  mus- 
cular system,  and  may,  therefore,  be  useful  in  the  intervals  when  rest 
from  the  more  active  treatment  is  re- 
quired. In  rotary  lateral  curvature  a 
pelvic  band  with  crutch  heads  extend- 
ing up  into  the  arm-pits  may  be  worn. 
A  jacket  or  cuirass  of  gypsum  bandages 
fitted  to  the  patient  when  he  is  sus- 
pended, to  straighten  out  the  curves, 
has  advocates.  If  these  means  pre- 
vent increase  of  the  deformity  and  aug- 
ment normal  muscular  development, 
the  tendency  to  spinal  deviation  will 
disappear  as  the  patient  grows  older. 

If  the  lateral  deformity  depends 
upon  one  leg  being  shorter  than  the 
other,  the  lower  extremities  should  be 
made  of  equal  length  by  increasing  the 
thickness  of  the  sole  of  the  shoe  on  the 
short  limb.  It  is  possible  that  making 
the  legs  of  unequal  length  by  wearing 

a  high  sole  may  be  utilized  as  a  treatment  for  correcting  spinal  curvature 
from  other  causes  than  asymmetry  of  limbs. 

Kyphosis  requires  a  similar  kind  of  treatment,  though  the  muscular 


Fib.  461. 


Diagram  of  dorsal  kyphosis  before  and 
after  application  of  a  spring  corrector. 
(Reeves.) 


'34 


DEFORMITIES,  OR    ORTHOPEDIC    SURGERY. 


exercise  should  be  adapted  to  the  character  of  the  deformity.  The  spring 
corrector  applied  in  ninny  cases  is  represented  in  the  figure. 

If  ankylosis  of  the  vertebnc  has  occurred,  cure  is  not  to  be  expected. 
Rupture  of  such  osseous  or  fibrous  bands  has  in  some  cases  been  attempted, 
and  has  been  successful.  There  is  an  element  of  danger  in  this  forcible 
method  of  treatment,  which,  of  course,  .should  never  be  applied  in  anky- 
losis after  tuberculosis  of  the  spine  or  Pott's  disease,  which  is  sometimes 
included  under  the  term  kyphosis. 

Lordosis  is  managed  in  a  similar  manner,  but  the  pressure  from  the 
apparatus  is  so  applied  as  to  push  forward  and  compress  the  dorsal  curve. 
The  patient's  shoulders  and  hips  may  be  so  elevated  when  lying  in  bed  as 
to  diminish  the  lumbar  curve,  and  thus  tend  to  correct  the  deformity.  It 
must  be  evident  that  for  the  successful  management  of  spinal  curvature, 
some  ingenuity  on  the  part  of  the  surgeon  will  be  required.  Although 
the  aid  of  steel  springs  and  rubber  bunds,  and  other  mechanical  appli- 
ances is  often  essential,  it  is  upon  the  muscles  that  dependence  is  to  be 
placed  in  preventing  and  overcoming  the  distortion.  Much  patience  is 
demanded  on  the  part  of  the  patient. 


Webbed  Fingers. 

The  term  webbed  fingers  is  applied  to  the  congenital   deformity  in 
which  two  or  more  fingers  are  fastened  together  by  cellulo-cutaneous 

Fh;.  4r,2. 


Operation  for  webbeil  fingers.  First  two  figures  show  lines  of  incision  on  back  and 
front  of  fingers.  Third  figure  shows:  a.  The  lines  of  the  two  incisions  uniting  so  as  to 
divide  the  web  and  leave  a  flap  on  each  side.  b.  The  flaps  detached  from  one  finger 
while  adherent  to  the  other,  c.  The  flaps  applied  to  the  fingers  and  covering  the  raw 
surfaces.     (Reeves,  i 

bands  extending  across  the  inter-digital  notch.     The  band  may  unite  the 
fingers  throughout  their  entire  length,  or  may  join  only  small  portions  of 


CLUB-FOOT,'  735 

them.  The  deformity  is  only  relievable  by  operation.  One  of  the  best 
plastic  operations  is  to  dissect  a  rectangular  flap  from  the  back  of  one  of 
the  fingers  extending  as  far  as  its  middle  line,  and  to  raise  a  similar  flap 
from  the  palmar  surface  of  the  other  finger  extending  as  far  as  its  middle 
line.  The  base  of  each  of  these  flaps  is  of  course  left  attached  to  the 
finger  from  which  it  is  not  taken,  and  extends  over  the  web  between  the 
webbed  digits.  The  subcutaneous  tissue  uniting  the  fingers  is  then 
divided,  and  the  flaps  carried  around  the  sides  of  the  two  fingers  in  such 
a  way  as  to  have  the  two  cutaneous  surfaces  presenting  toward  each  other 
on  the  proximal  sides  of  the  previously  united  digits.  If  some  such 
method  is  not  adopted  the  raw  surface  made  by  cutting  the  fingers  apart 
would  unite  at  the  base  during  cicatrization,  despite  the  utmost  care  and 
thorough  dressing. 

Club-foot. 

Pathology. — Talipes,  or  club-foot,  is  a  deformed  position  of  the  foot, 
or  part  of  the  foot,  in  relation  to  the  leg.  It  may  be  congenital  or 
acquired.  Usually  the  muscles,-  fascias  and  ligaments  are  contracted ; 
sometimes  the  bones  and  cartilages  themselves  are  misshapen.  The  de- 
formity may  dej)end  upon  congenital  malformation  of  the  structures  of 
the  foot,  upon  spasm  of  the  contracted  muscles,  upon  paralysis  of  the 
muscles  which  normally  should  oppose  the  contracted  muscles,  and  upon 
other  displacing  agencies.  Wasting  of  the  muscles  occurs  secondarily, 
atrophy  of  the  foot  and  leg  results,  and  subcutaneous  burs^e  are  developed 
at  points  upon  which  pressure  comes  during  walking. 

Congenital  cases  present  a  very  great  amount  of  distortion  when  the 
child  is  allowed  to  attain  adult  age  without  the  adoption  of  projDer  means 
to  cure  the  deformity. 

Fig.  463.  '  Fig.  464. 


Pes  varus  in  the  adult.      (Treves.)  Pes   calcaneus.      The  foot  before  and  after 

section  of  the  tendo-Achillis.    (Tkevks.) 

There  are  six  varieties  of  talipes  : 

1.  Pes  varus  ;  in  which  the  inner  side  of  the  foot  is  raised,  and  the 
anterior  part  of  the  foot  and  the  sole  turned  inward. 

2.  Pes  valgus.     This  condition  is  the  opposite  of  pes  varus,  and  in  it 
the  outer  side  of  the  foot  is  raised  and  the  sole  turned  outward. 

3.  Pes  equinus.     Here  the  heel  is  raised  and  the  patient  walks  on  the 
toes. 

4.  Pes  calcaneus  is  the  opposite  of  pes  equinus.     The  toes  are,  there- 
fore, raised  and  the  patient  walks  upon  his  heel. 

5.  Pes  planus  ;  in  which  the  arch  of  the  foot  is  sunken  and  the  entire 
sole  rests  upon  the  ground  when  walking. 

6.  Pes  cavus  is  the  opposite  of  pes  planus.     In  it  the  arch  of  the  foot 
is  increased  and  there  is  a  great  hollow  in  the  sole. 


736  DEFORMITIES,    OR    ORTHOPAEDIC    SURGERY. 

These  six  forms  of  talipes  are  the  types,  but  the  forms  may  be  variously 
combined.  For  example:  In  e(juiin)-varu.-f  the  heel  is  raised  and  the 
patient  has  the  inner  side  of  the  foot  elevated  and  the  sole  turned  inward, 
while  pes  calcaneo-valgus  is  a  form  in  which  the  patient  walks  upon  the 
heel  with  the  sole  turned  outward. 

Fig.  46(i. 


Pes  valgus,  or  flat-foot.     (Treves.)  Pes  cavus,  or  hollow-foot.    (Treves  ) 


Treatment. — The  treatment  of  club-foot  requires  many  months  and 
a  combination  of  operative,  mechanical,  and  physiological  measures. 
Manipulations  carried  on  for  months  by  the  patient's  nurse,  by  which  the 
muscles  are  developed  and  the  foot  forced  in  a  normal  condition,  will  fre- 
quently cure  slight  degrees  of  the  deformity.  In  other  cases,  tenotomy 
of  the  tendons  and  fascias  will  be  demanded,  and  will  have  to  be  sup})le- 
mented  with  manipulations  and  apparatus  in  order  to  maintain  the  cor- 
rected position  obtained  by  operation. 

The  most  confirmed  and  marked  cases  are  found  in  adults  who  have 
gone  untreated.  In  these,  and  sometimes  in  very  severe  cases  occurring 
in  the  young,  excision  of  some  of  the  tarsal  bones  is  the  only  means  by 
which  a  fairly  good  position  of  the  distorted  member  can  be  obtaine<i. 
It  is  rather  rare  that  this  severe  operation  is  demanded  in  cases  of  con- 
genital club-foot  which  come  under  skilful  supervision  during  infancy. 
Cases  of  unsuccessfully  treated  club-foot,  commonly  called  relapsed  cases, 
are  more  difficult  to  handle  than  others  presenting  similar  deformity, 
becau.se  after  tenotomy  has  been  done  the  patient's  tendons  and  fascias 
become  more  or  less  matted  together  by  adherent  inflammation.  Of  late 
years,  immediate  correction  of  the  deformity  by  great  force,  applied  by 
the  hands,  or  by  means  of  screws  operating  upon  pads  applied  to  the  foot, 
has  become  a  favorite  with  some  orthopaedic  surgeons.  The  corrected 
position  so  produced  is  maintained  by  the  application  of  gypsum  bandages 
to  hold  the  foot  in  place. 

The  operation  of  tenotomy  may  l)e  done  upon  infents  after  two  months 
of  life,  if  by  this  time  efforts  to  overcome  the  deformity  by  manipulation 
have  been  unavailing,  and  in  cases  where  it  is  evident  that  these  simple 
measures  will  not  be  of  service  if  they  are  kept  up.  After  tenotomy  the 
foot  and  leg  should  be  bandaged  to  a  well-padded  splint  of  zinc,  co])per, 
or  sheet  iron,  which  will  maintain  the  desired  position.  These  flexible 
splints  are  cheap  and  can  be  altered  from  time  to  time  as  the  surgeon  de- 
sires. They  facilitate  greatly  the  change  in  position  of  the  foot  which  is 
the  object  of  treatment.  After  six  weeks'  use  of  the  splint  it  may  be  dis- 
pensed with  in  congenital  cases,  but  the  little  patient  should  be  under  the 
surgeon's  eye  at  intervals  until  able  to  walk,  and  should  even  be  watched 
bv  him  after  that  date. 


CLUB-FOOT. 


737 


The  greatest  care  is  necessary  to  see  that  excoriations  are  not  produced 
by  the  apparatus  applied.  Massage  in  its  various  forms  should  be  con- 
tinued during  treatment.  It  is  essential  that  the  muscles  of  the  leg  be 
subjected  to  the  influence  of  massage  as  well  as  those  of  the  foot. 


Fig.  467. 


Fig.  468. 


Eeeves's  universal  talipes  shoe. 


Eeeves-Scarpa  shoe  for  severe  cases. 


Pes   Varus. 

This  is  the  most  frequent  form  of  congenital  club-foot.  There  is  inver- 
sion of  the  anterior  two-thirds  of  the  foot,  with  turning-in  of  the  sole  and 
elevation  of  the  inner  part  of  the  foct,  so  that  the  patient  walks  upon  the 
outer  part,  or,  in  bad  cases,  actually  upon  the  dorsum,  of  the  tarsus. 

In  all  cases  of  pes  varus  there  is  elevation  of  the  heel,  producing  pes 
equino-varus.  The  inversion  is  due  to  the  anterior  tibial  and  posterior 
tibial  muscles,  and  the  long  flexor  muscles  of  the 
toes,  while  the  elevation  of  the  heel  is  produced  by 
the  calf  muscles  acting  through  the  tendon  of 
Achilles.  The  plantar  fascia  and  other  muscles 
than  those  mentioned  may  at  times  be  contracted, 
and  increase  the  deformity. 

Treatment. — It  is  usually  well  in  undertaking 
operative  treatment  for  this  condition  to  divide  the 
operation  into  two  stages  if  the  deformity  is  a  pes 
equino-varus  and  not  a  simple  pes  varus.  The  in- 
version of  the  foot  should  be  first  treated  by  ten- 
otomy of  the  tibial  tendon  and  of  the  posterior  tibial 
tendon.  Perhaps  the  plantar  fascia  and  some  of  the 
other  tendons  may  require  section.  The  second 
stage,  which  is  to  relieve  the  elevation  of  the  heel, 
should  be  undertaken  several  weeks  later.  If  the 
case  is  one  of  pure  pes  varus,  the  first  procedure 
alone  is  necessary. 

After  the  deformity  has  been  corrected  by  means 
of  tenotomy,  the  foot,  of  course,  is  dressed  with  the 
flexible  metal  splints  previously  described,  or  possibly  with  gypsum  ban 
dages.     The  latter,  however,  is  not  so  desirable  in  infants  as  in  club-foo 

47 


Diagram  of  a  normal 
foot  and  one  with  pes 
equino-varus,  to  show- 
internal  deviation  of 
the  anterior  part  of 
foot.     ^Satre.) 


738  DEFORMITIES,    OR    ORTHOPAEDIC    SURGERY. 

of  adults,  because  the  skin  is  tender  and  more  easily  irritated.  It  is, 
therefore,  better,  if  possible,  to  use  metal  splints,  which  can  be  removed 
daily,  in  order  that  the  limb  may  be  bathed  and  the  condition  of  the  foot 
observed. 

In  pes  varus  or  equino-varus,  whether  due  to  congenital  or  acquired 
causes,  more  radical  ()j)erations  are  sometimes  demanded.  Free  tenotomy 
of  all  the  restricting  structures,  without  reference  to  their  names,  accom- 
panied in  many  cases  by  the  removal  of  a  wedge-shaped  portion  of  the 
tar.sal  bones,  is  at  times  the  only  method  which  will  give  a  proper  shaped 
foot.  Cutting  out  a  wedge-shaped  portion  of  bone  is  called  tarsectomy, 
and  is  performed  by  making  a  large  elliptical  Hap  to  expose  the  bones, 
and  removing  with  a  saw,  or  by  disarticulating  with  a  knife,  all  the  bony 
tissues  that  i)revent  the  reposition  of  the  foot.  A  drainage-tube  is  then 
introduced,  the  flaps  and  such  tendons  as  are  not  factors  in  causing  de- 
formity are  united  by  sutures,  and  the  limb  dressed  with  gypsum  im- 
movable dressings.  The  dressing  may  be  left  in  j)Osition  for  several 
weeks,  when,  if  the  asepsis  or  antisepsis  has  been  perfect,  the  wound  will 
be  found  healed,  except  at  the  point  where  the  drainage-tube  makes  its 
exit.  The  gypsum  bandage  may  be  removed,  however,  at  an  early 
jjeriod,  in  order  to  take  out  the  drainage-tube.  After  such  operations  the 
foot  is  always  shorter  than  the  normal  foot  would  be.  This  is  due  partly 
to  the  removal  of  a  portion  of  the  tarsus,  and  partly  to  the  fact  that  the 
leg  and  foot  are  atrophied  from  imperfect  development  or  from  non-use 
of  the  muscles.  Tarsotomy  is  the  term  used  when  the  bones  are  simply 
cut  through  with  a  saw  or  chisel  and  no  portion  removed.  This  is  some- 
times effective.  Occasionally,  reposition  of  the  inverted  foot  may  be 
accomplished  by  forcibly  bending  it  into  i)osition  by  means  of  the  hands 
or  strong  screws  attached  to  a  suitably-shaped  foot-clamp.  Some  slight 
inflammatory  reaction  is  to  be  expected  after  this  violent  treatment. 
Apparatus  or  dressings  of  a  retentive  kind  must  be  applied  after  the 
operation. 

Pes  Vcdgus. 

Pes  valgus  is  the  condition  opposite  to  pes  varus,  and  is  the  turning-out 
of  the  sole,  so  that  the  patient  walks  upon  the  inner  edge  of  the  foot.  It 
is  very  frequently  associated  with  flattening  of  the  arch  of  the  foot,  be- 
coming then  pes  i)lano-varus.  It  is  sometimes  combined  with  i)es  cal- 
caneus, and  is  then  called  pes  calcaneo-valgus.  Mild  cases  are  man- 
aged by  bandaging  the  foot  into  proper  position  by  sj^lints  and  pads 
placed  on  the  inner  side  of  the  ankle.  In  more  severe  eases  tenotomy  of 
the  three  peroneal  muscles,  and  of  any  other  muscles  tending  to  produce 
displacement,  may  be  required.  If  the  sole  is  flat,  it  may  be  necessary  to 
insert  in  the  shoe  worn  after  the  lateral  deformity  has  been  corrected, 
such  a  pad  as  will  restore  the  arch  of  the  foot.  Resection  of  the  astragalo- 
scaphoid  joint  may  be  required  to  restore  the  arch. 

Pes  Equinns. 

This  deformity  is  not  often  congenital.  It  is  usually  due  to  infantile 
paralysis  of  the  muscles  of  a  part  of  the  leg,  or  to  abscess  or  injury  caus- 
ing contraction  of  the  calf  muscles.  It  is  to  be  treated  by  tenotomy  of 
the  tendon  of  Achilles. 


CLUB-FOOT.  739 


Pes   Calcaneus 


Pes  calcaneus  is  another  form  of  club-foot  which  is  not  commonly  con- 
genital, and,  like  pes  equinus,  is  quite  often  due  to  infantile  paralysis  of 
the  muscles  antagonistic  to  those  producing  the  deformity.  Pes  calcaneus 
is  treated  by  tenotomy  of  the  displaced  muscles,  or  by  apparatus  so 
arranged  as  to  pull  up  the  heel.  Rubber  bands  are  utilized  in  this  as 
in  other  forms  of  club-foot.  It  has  been  suggested  to  cut  out  a  portion 
of  the  tendon  of  Achilles  and  splice  the  two  ends,  in  order  to  raise  the 
heel  and  shorten  the  tendon  of  the  calf  muscles. 

Pes  Planus. 

Pes  planus,  or  flat-foot,  is  a  flattened  sole,  due  to  obliteration  of  the 
normal  arch  of  the  instep.  This  form  of  club-foot  is  well  demonstrated 
by  covering  the  sole  with  shoe  blacking  and  having  the  patient  tread 
upon  a  piece  of  white  paper.  The  imprint  of  the  foot  shows  the  entire 
foot  coming  in  contact  with  the  floor,  and  is  a  good  diagnostic  symptom 
of  the  existence  of  the  deformity.  In  the  normal  foot  it  is  simply  the 
heel,  outer  edge,  and  the  toes  that  touch  the  ground. 

Fig.  470. 


Impression  of  normal  sole,  with  dotted  lines         Impression  of  the  sole  in  pes  cavu?. 
showing  borders  of  the  foot.     (Reeves.)  (Reetes.) 

The  pain  produced  by  this  giving  way  of  the  plantar  arch  is  often 
mistaken  for  rheumatism  or  neuralgia.  This  breaking  down  occurs  in 
persons  of  weak  fibre,  in  those  who  are  required  to  stand  much  upon 
their  feet,  and  in  those  who  are  very  heavy.  An  ingrowing  toe-nail 
may  cause  it  by  reason  of  the  manner  of  walking  adopted  to  avoid  pain 
from  the  diseased  nail.  As  previously  stated,  the  condition  is  often  as- 
sociated with  pes  valgus.  Much  comfort  is  often  given  by  placing  in  the 
shoe  a  plate  or  pad  to  restore  the  arch  of  the  foot.  Muscular  tone  can 
be  ^iven  the  long  flexor  of  the  great  toe  by  gymnastic  exercises  to 
develop  the  muscle.  This  may  be  done  by  having  the  patient  raise 
himself  upon  his  toes  a  number  of  times  each  morning,  so  as  tobrmg 
these  muscles  into  action.  "Weak  ankles"  is  a  term  often  applied  to 
a  tendency  to  the  occurrence  of  pes  valgus,  and  is  due  to  the  relaxa- 
tion of  the  internal  lateral  ligament  of  the  ankle-joint.  Massage  and 
support  of  the  ankle  by  a  high-laced  shoe,  or  some  form  of  rubber  or 


740 


DEFORMITIES,    OR    ORTHOPEDIC    SURGERY, 


metal  support,  will,  when  eoinbiued  with  tonic  treatment,  usually  be  suffi- 
cient for  the  correction  of  this  weakness. 

Pes  cavus,  or  hollow-foot,  is  treated  by  subcutaneous  division  with  a 
tenotome  of  the  plantar  fascia,  with  or  without  division  of  the  short 
flexor  muscle  of  the  toes.  Improvement  in  gait  and  relief  from  discom- 
fort are  sometimes  obtained  by  buildin<r  up  the  interior  of  the  shoe  so 
that  the  sole  will  come  in  close  contact  with  the  excessive  arch  of  the  foot. 


Deformities  of  the  Knee  and  Leg, 


Pathology. — Knock-knee,  or  genu-valgum,  is  a  deformity  in  which, 
when  the  patient  is  standing,  the  knees  are  close  together  or  touch, 
while  the  internal  malleoli  are  more  or  less  widely  separated.  The 
opposite  condition,  in  which,  when  the  internal  malleoli  touch,  the  knees 
are  more  or  less  widely  separated,  is  called  genu-varum,  or  bow-legs. 
This  latter  condition  is  frequently  associated  with  bowing  outward  of  the 
tibias. 


472. 


Fio.  473. 


LENTZ' 
{SONS 


Apparatus  for  treating  knoek-knoe. 


Apparatus  for  treating  bow-leg. 


The  deformity  in  knock-knee  disappears  when  the  knees  are  bent  so 
as  to  bring  the  legs  at  right  angles  to  the  thighs.  In  this  deformity 
there  is  not  much  pain,  but  usually  a  feeling  of  weakness  after  prolonged 
standing  or  walking,  which  may  be  associated  with  con.siderable  discom- 
fort. The  deformity  exhibited  in  the  lower  extremities,  and  the  abnor- 
mality in  gait  of  the  patient,  are  sufficiently  diagnostic.  The  condition 
may  be  due  to  rickets,  but  it  may  also  occur'from  attempts  at  walking  at 
too  early  a  period  while  the  bones  and  ligaments  are  scarcely  developed 
in  strength.  Local  paralysis,  or  a  continuation  of  bad  postures  in  early 
life,  may  also  be  factors  in  the  causation  of  genu-valgum.  The  knee- 
joint  shows  a  tendency  to  bend  backward  so  that  the  popliteal  space 
scarcely  exists.     The  inner  condyle  appears  relatively  larger  when  com- 


I 


DEFOEMITIES    OF    THE    KNEE    AND    LEG.  741 

pared  with  the  extei'iial  condyle,  but  it  is  possible  that  this  change  of 
relation  is  due  to  improper  development  of  the  shaft  of  the  bone. 

Treatment. — In  the  early  stages  such  joint  deformities  are  often  reme- 
diable by  the  use  of  apparatus  which  will,  in  case  of  knock-knee,  draw 
the  knee  outward,  and  in  the  case  of  bow-legs  press  the  tibia  or  knee 
inward. 

In  more  advanced  cases  it  becomes  necessary  to  use  more  active  meas- 
ures. This  consists  in  forcibly  straightening  the  deformed  limbs  by 
manual  power  or  by  performing  osteotomy,  followed  by  the  application 
of  gypsum  bandages  to  retain  the  fractured  or  cut  tissues  in  their  new 
position. 

Osteotomy  is  usually  performed  by  means  of  a  chisel  or  osteotome.  The 
latter  is  an  instrument  much  like  a  chisel,  except  that  it  is  bevelled  on 
both  sides  instead  of  upon  one.  A  saw  is  seldom  used  at  the  present  time 
for  performing  osteotomy. 

Fig.  474. 


Osteotome. 

In  case  of  knock-knee  the  femur  may  be  divided  by  a  horizontal  cut 
just  above  the  external  condyle,  or  at  the  junction  of  the  middle  and  lower 
thirds.  The  relatively  large  internal  condyle  may  be  separated  from  the 
rest  of  the  femur  by  an  oblique  cut  made  with  the  osteotome,  so  that  the  con- 
dyle will  slip  upward  when  the  leg  is  brought  inward  to  a  normal  posi- 
tion. Some  operators  prefer  condyloid  section ;  others,  section  above  the 
condyles,  or  in  the  shaft.  In  performing  osteotomy  it  is  proper  that  the 
incision  through  the  skin  should  be  made  in  the  long  axis  of  the  bone,  in 
order  to  divide  as  few  muscular  fibres  and  tendons  as  possible.  The  osteo- 
tome is  introduced  with  its  edge  in  the  direction  of  the  incision,  but  sub- 
sequently it  is  turned  to  a  right  angle  before  it  is  struck  with  the  mallet. 
The  bone  should  be  divided  for  about  two-thirds  of  its  thickness.  The 
remaining  portion  of  the  bone  is  fractured,  as  the  limb  is  bent  into  posi- 
tion. In  the  condyloid  section  the  instrument  should  not  go  entirely 
through  the  condyle  so  as  to  enter  the  joint.  Section  through  two-thirds 
of  the  bone  at  this  point  Avill  permit  ready  fracture  of  the  remaining 
osseous  tissue ;  and  the  line  of  fracture  is  not  so  liable  to  cause  inflamma- 
tion of  the  joint  as  would  one  made  by  the  instrument,  although  an  aseptic 
wound  of  this  sort  is  not  apt  to  cause  any  complication.  Some  surgeons 
prefer  to  make  the  section  through  the  shaft  of  the  femur  from  the  inter- 
nal aspect  of  the  thigh  rather  than  through  the  external  sui-face.  By 
some  operators  it  is  thought  advantageous  to  use  one  or  two  osteotomes, 
each  of  lessened  thickness,  for  the  deeper  parts  of  the  bone  section.  The 
thick  osteotome  makes  the  wound  at  the  surface  of  the  bone  wide ;  the 
thinner  instruments  cause  a  narrower  cut  as  the  deeper  portion  of  the 
bone  is  divided.  This  gives  the  wound  in  the  bone  when  completed  the 
wedge-shape  which  is  believed  by  them  to  render  correction  of  the  deform- 
ity more  satisfactory.  This  theoretical  advantage  does  not  seem  to  be 
altogether  sustained'by  practical  experience,  and  the  change  of  instruments 
renders  sepsis  more  possible. 


742  DEFORMITIES,    OR    ORTHOPEDIC    SURGERY. 

Osteotomy  is  frequently  required  in  cases  of  bow-legs.  Sometimes  it 
is  necessary  to  divide  both  the  tibia  and  the  femur. 

It  requires  from  four  to  six  weeks  for  the  divided  bone  to  unite  after 
osteotomy  for  genu-valgura  or  genu-varum.  After  this  time  the  gypsum 
dressing,  which  is  usually  applied  over  the  antiseptic  dressing  immedi- 
ately after  the  operation,  may  be  removed.  For  a  long  time  afterward 
apparatus  is  demanded  in  order  that  a  recurrence  of  the  deformity,  or 
fracture  of  the  bone  at  the  point  of  operation,  may  not  occur. 

Various  irregular  deformities  of  the  tibia  may  occur  as  a  result  of 
rickets.  These  may  demand  for  their  alleviation  numerous  osteotomies, 
or  in  some  cases  excision  of  a  wedged-shaped  piece  of  bone. 


CHAPTEIi    XXYI. 

AMPUTATIONS. 

Definition. — By  amputation  is  meant  the  removal  of  a  locomotor 
extremity  of  the  body. 

Varieties. — Amputations  may  be  single,  double,  or  multiple ;  partial 
or  complete.  Multiple  when  more  than  two  extremities  are  removed  at 
the  same  sitting.  When  two  or  more  operators  at  once  remove  separate 
extremities  the  operation  is  termed  synchronous  amputation. 

Complete  when  an-  entire  extremity-  is  removed,  as  the  leg  at  the  knee, 
termed  complete  amputation  of  the  leg ;  or  the  thigh  at  the  hip,  known 
as  complete  removal  of  the  thigh.' 

Partial  when  amputation  is  done  within  the  extreme  limits  of  an 
extremity.  Thus,  an  operation  removing  but  a  portion  of  the  forearm 
would  be  a  partial  amputation,  but  operation  through  the  elbow-joint 
would  be  a  complete  amputation  of  the  forearm.  Amputations  are  some- 
times spoken  of  as  in  contiguity  or  continuity ;  in  contiguity  when  done 
between  contiguous  bones  at  joints,  as  amputations  through  the  elbow- 
joint  ;  and  in  continuity  when  division  is  made  in  the  continuity  of  bones 
between  joints,  as  in  the  middle  of  the  thigh.  Amputations  may  be 
natural,  as  those  produced  in  utero  by  the  umbilical  cord  or  other  con- 
stricting bands,  or  by  the  shedding  of  a  part  by  gangrenous  process; 
traumatic,  as  when  an  extremity  is  cut  or  torn  oiF  by  machinery  or  pro- 
jectiles ;  or  as  surgical  premeditated  scientific  procedure. 

Reamputations  are  either  done  subsequently  to  an  unsuccessful  ampu- 
tation at  a  lower  point,  for  disease  of  a  stump,  or  to  put  into  better  shape 
the  result  of  a  natural  or  accidental  amputation.  The  mere  trimming-up 
of  an  extremity  non-operatively  removed  should  never  be  termed  amputa- 
tion or  reamputation. 

The  objects  of  amputation  are  completely  to  rid  the  patient  of  a  danger- 
ous devitalized  or  impedimental  extremity,  which  cannot  otherwise  be 
treated  with  beneficial  results,  and  in  so  doing  to  leave  him  as  useful  a 
stump  as  possible.  These  being  the  objects  of  amputation  it  can  readily 
be  understood  why  wath  the  advance  of  surgical  knowledge  the  operation, 
especially  for  chronic  disease  and  wound  complications,  is  each  year  less 
frequently  employed. 

Indications. — Amputation  may  be  indicated  when  an  extremity  has 
been  hopelessly  crushed,  or,  at  a  higher  point,  when  an-  extremity  has  been 
avulsed  or  torn  off;  wdien  the  limb  is  destroyed  by  heat,  frost-bite,  or  gan- 
grene ;  for  certain  encircling  and  other  incurable  ulcers,  and  for  morbid 
growths  and  deformities. 

CoNTRA-iNDiCATiONS. — Amputatious,  unless  extenuating  circumstances 
are  present,  should  not  be  undertaken  when  shock,  nephritis,  diabetes, 
pyemia,  general  tuberculosis,  or  atheromatous  vessels  are  present.  In 
spreading  gangrene  it  will  often  be  the  patient's  only  chance  for  life,  but 
in  all  other  forms  of  the  affection  the  operation  should  be  delayed  until 
a  line  of  demarcation  can  be  distinctly  recognized. 


744  AMPUTATIONS. 

Time  for  Amputations — According  to  certain  constitutional  condi- 
tions wluch  are  present  in  cases  demanding  amputation  the  operation  is 
termed  (1)  primary,  (2)  secondary,  or  (3)  tertiary. 

(1)  Primary  amputations  are  those  which  are  performed  for  injury  at 
once,  or  before  septic  absorption  and  consequent  constitutional  disturb- 
ance has  taken  place.  The  primary  is  the  elective  period  if  shock  can 
be  subdued,  and  the  general  condition  of  the  patient  warrants.  When 
the  injured  part  is  kept  aseptic  the  jiriniary  period  can  be  indefinitely 
prolonged,  but  otherwise  it  will  terminate  in  not  less  than  twenty  or  more 
than  forty-eight  hours  after  injury,  varying  greatly  with  different  indi- 
viduals, the  degree  of  shock,  and  the  virulence  of  infection. 

(2)  Secondary  or  intermediary  amputations  are  those  performed  while 
the  septic  process  is  developing  and  in  active  jjrogress.  This  period  usu- 
ally begins  from  tweuty-four  to  thirty-six  hours  after  injury,  its  duration 
may  be  days,  weeks,  or  months.  There  would  be  no  secondary  ])erioil 
following  traumata  if  the  wounds  could  be  treated  early  enough  and 
in  thoroughly  antiseptic  manner.  To  the  secondary  period  also  belong 
all  premeditated  amputations  for  acute  septic  disorders,  such  as  spreading 
gangrene,  or  abscess  of  a  joint.  Secondary  amputations  yield  a  very  high 
death-rate,  and  should  only  be  undertaken  for  such  desperate  circum- 
stances as  rapidly  extending  gangrene,  or  where  it  is  thought  to  be  a 
greater  risk  to  allow  the  disorder  to  continue  than  to  remove  the  extremity 
at  so  dangerous  a  time. 

(3)  Tertiarv  ( chronic")  amputations  are  those  performed  after  the  septic 
process  has  terminated  or  become  chronic,  and  the  patient  well  acclimatized 
to  his  altered  state ;  also  those  performed  for  growths,  simple  aneurisms, 
chronic  disease,  deformities,  and  supernumerary  extremities. 

Location  of  Ampltatiox. — The  point  at  which  amputation  shall  be 
made  is  determined  by  the  nature  and  extent  of  injury;  the  presence  of 
multiple  fractures  ;  of  bloodvessel  implication,  and  innumerable  other 
circumstances  which  present  with  each  individual  case.  But  a  good 
general  rule  is  to  amputate  as  far  from  the  trunk  as  is  consistent  with 
thoroughness  of  removal,  certainty  of  result,  and  subsequent  utility  of  the 
stump."  The  mortality  of  amputations  rises  as  the  seat  of  operation  ap- 
proaches the  trunk.  In  each  extremity  there  are  situations  which,  for 
various  reasons,  are  more  favorably  regarded  as  pobits  of  election  for 
amputations  than  others.  Thus,  the  lower  middle  of  the  leg  is  the  point 
of  election  for  amputating  the  leg,  because  an  artificial  member  can  be 
best  adjusted  at  that  situation  ;  amputation  just  far  enough  below  the 
elbow  to  retain  the  tubercle  of  the  radius,  is  vastly  better  than  one  through 
the  joint,  as  in  the  former  the  ])ower  of  flexing  an  artificial  forearm  is 
preserved.  When  operating  for  malignant  disease,  the  site  of  amj)utation 
must  widely  clear  the  affected  area,  and,  if  bone  is  involved,  the  extremity 
should  be  removed  at  a  point  not  lower  than  the  first  articulation  above. 
Every  possible  atom  of  the  hand  is  worth  preserving,  but  no  risk  is  worth 
taking  to  save  toes  or  small  portions  of  the  foot. 

The  arm,  forearm,  thigh,  and  leg,  are  each  divided  into  approximate 
thirds,  that  the  seat  of  amputation  may  be  more  accurately  described. 
Thus  we  speak  of  amputation  in  the  lower  third  of  the  arm,  the  upper 
third  of  the  leg,  or  the  middle  third  of  the  forearm. 

Instrument.^. — In  addition  to  ordinary  operating  instruments,  there 
will  be  required  for  amputations  various  special  saws  and  knives,  a  double- 
edged  knife  rcatlin;  for  dividing  tissues  between  the  bones  of  the  forearm 
and  leg,  cutting  pliers  and  bone  forceps.    Also  tourniquets,  the  hemostatic 


OPERATIVE     METHOD. 


745 


rubber  bandage,  and  retractors  for  holding  soft  parts  a^vay  from  the  saw. 
These  latter  are  made  from  a  stout  piece  of  gauze  six  or  eight  inches  wide 
and  two  feet  long,  torn  through  half  its  length  into  two  tails,  if  but  one 
bone  is  present,  or  into  three  tails  if  two  bones  are  to  be  divided.  It  is 
applied  in  the  latter  case  by  covering  each  half  of  the  divided  tissues  with 
the  outside  strips,  and  slipping  the  middle  one  between  the  bones ;  by 
traction  upon  the  ends  all  tissues  can  then  be  drawn  upward  out  of  reach 
of  the  saw. 

Fig.  475. 


Amputating  knite  and  catim. 
Fig.  47ri. 


Aseptie  amputation  saw. 


13 


Operative  Method. — Primary  amputations  will  often  be  necessary 
when  the  patient's  condition  is  far  from  favorable,  but  in  tertiary  opera- 
tions we  should  get  him  into  the  very  best  general  and  local  condition 
before  operation  is  undertaken.  In  operating  we  should  aim  to  sacrifice 
as  little  healthy  tissue  and  lose  as  little  blood  as  possible ;  to  j^rovide  a 
sufficient  bone  covering ;  to  divide  bloodvessels  and  nerves  transverely, 
and  to  insure  thorough  drainage  and  asepsis  of  the  wound. 


Fig.  477. 


Esmarch's  avascularization  a23paratus. 

;More  or  less  complete  avascularity  should  be  secured  by  the  rubber 
bandage,  tourniquet,  or  other  means,  but  only  elevation  and  simple  tourni- 
quet should  be  employed  when  abscesses,  gangrene,  or  malignant  tumors 
are  present,  for  fear  of  producing  metastasis. 

Incisions  are  generally  made  from  above  downward,  and  from  without 


746 


AMPUTATIONS. 


Frr..  47'?. 


inward  to  deep  fascia,  and  the  muscles  divided  at  a  hi<rlier  point  subse- 
quently. But  occasionally  the  method  of  transfixion,  where  the  knife  is 
carried  directly  through  the  centre  of  the  limb,  and  the  muscles  and  in- 
tegument divided  en  mas.<e  as  the  knife  is  brought  to  the  surface,  may  be 
employed  with  advantage.  Incisions  may  be  made  in  any  manner  or 
direction,  provided  that  they  yield  a  well-nourished  covering  for  the  end 
of  the  remaining  portion  of  extremity.  The  coverings  (the  Haps)  should 
be  so  devised  and  proportioned  that  there  shall  be  no  tension  upon  them, 
that  they  shall  be  well  supplied  with  bloodvessels,  and  that  when  the  wound 

has  healed  the  resulting  scar  shall  be 
neither  over  the  bone  end  nor  so  placed 
as  to  interfere  with  the  wearing  of  an 
artificial  limb.  Ordinarily,  the  num- 
ber of  flaps  should  not  exceed  two; 
but  where  there  is  extensive  destruc- 
tion of  integument  the  surgeon  may 
be  driven  to  any  kind  of  patchwork 
to  provide  sufficient  covering  for  a 
stump,  which  otherwise  must  have  been 
made  much  shorter.  Extra  length  of 
flaps  is  of  little  consequence,  for  they 
can  then  be  trimmed  down,  but  the 
greatest  precaution  must  be  taken  to 
have  them  not  too  short  or  narrow.  A  safe  rule  is  to  cut  flaps  so  that  their 
combined  length  is  not  less  than  two-thirds  the  circumference  of  the  limb 
at  the  point  of  boue  division.  Their  combined  width  should  equal  the 
circumference  at  that  point.  They  may  be  cut  of  equal  size,  or  one  long 
and  the  other  short,  in  varying  degree ;  antero-posterior  or  lateral ; 
simply  cutaneous  or  musculo-cutaneous. 

When  amputation  is  made  by  circular  incision  (the  so-called  circular 
method)  the  skin  of  the  extremity  is  grasped  by  the  left  hand,  drawn 
upward,  and  steadied,  while  the  right  hand  holding  a  long  amputating 
knife  is  passed  around  the  limb  until  the  surgeon  looks  upon  its  dorsal 
surface.  The  heel  of  the  knife  is  then  sunk  through  the  integument, 
and  as  the  hand  is  brought  back  around  the  limb  the  incision  is  com- 
pleted. A  cufl^ of  integument  is  then  dissected  up  and  turned  back  to 
the  proper  distance  to  make  a  sufficient  flap.  All  flap  dissections  in  ampu- 
tations should  be  done  with  the  knife  edge  directed  toward  the  muscles, 
that  the  bloodvessels  of  the  skin  may  be  least  injured.  The  muscles  are 
then  divided  to  the  bone  by  a  similar  circular  sweep  immediately  below 
the  point  up  to  which  the  flaps  have  been  dissected,  the  retractor  is  applied, 
and  any  interosseous  tissue  having  been  previously  divided  with  a  double- 

FiG.  479. 


Amputation  through  elbow-joint  by  cir 
cular  method. 


Alii]iUt;i 


1   I'l.  ill  III  by  modified  circular  method.     (Bryaxt.) 


edged  knife,  the  bone  or  bones  are  sawed  through  at  a  slightlyjhigher 
level ;  the  smaller  one  always  being  first  divided.  Any  chips  or  sharp 
spicules  of  bone  remaining  should  be  picked  out  or  cut  off"  with  forceps 


OPERATIVE    METHOD. 


747 


and  the  bone  ends  left  smooth.  Some  surgeons  prefer  to  cut  the  muscles 
at  once  down  to  periosteum  rather  than  to  cut  the  membrane  at  a  lower 
point  and  scrape  it  upward  as  a  flap  for  the  bone  end,  but  I  consider  this 
as  of  trivial  importance.  The  removed  part  is  then  placed  in  a  suitable 
receptacle,  the  sawdust  washed  away  with  a  stream  of  bichloride  solution 
and  all  attention  given  to  seeking  and  tying  the  arteries.  This  accom- 
plished, any  redundant  muscle  or  flap  is  cut  away,  the  ends  of  tendons 
and  nerves  drawn  down  and  cut  ofl",  and  the  tourniquet  loosened.  Every 
bleeding  jDoint  should  be  separately  grasped  by  forceps  or  tenaculum  and 
tied  with  catgut.  Extensive  or  continued  oozing  can  be  controlled  by 
very  hot  water  or  alcohol  applications.  Bleeding  from  the  bone  medulla 
should  be  arrested  by  the  same  means,  pressure  of  a  finger,  packing  with 
catgut,  or  the  cautery. 

Fig.  4S0. 


Fig.  481. 


Stump ;  showing  application  of  sutures  and  drain-tubes.     A  drainage-tube  is  shown 
at  the  left.     (Smith.) 

The  flaps  are  now  approximated  over  a  sufiicient  drain  by  catgut 
sutures  and  the  dressing  applied.  Two  flaps  may  be  made  after  circular 
incision  by  a  vertical  incision  on  each,  side  (modified  circular  method). 
When  thus  made  the  square  corners  of  the  flap  should  be  rounded  off. 
Amputation  by  circular  incision  is  only  applicable  to  the  arm  and  forearm. 

The  more  usual  method  of  amputation  is  that  by  double  cutaneous  or 
musculo-cutaneous  flaps,  made  almost  square  with  round  corners,  exactly 
rectangular,  or  oval.  These  are  made  usu- 
ally by  incision  from  above  downward  and 
from  without  inward,  but  may  also — that 
is,  the  musculo-cutaneous — be  made  by 
transfixion.  Cutaneous  flaps  with  circular 
division  of  muscles  are  generally  best. 
Excepting  in  shape  of  flaps  the  cutaneous 
method  is  identical  with  that  of  circular 
incision.  So,  also,  the  partially  musculo- 
cutaneous in  which  the  muscles  are  simi- 
larly divided,  but  at  a  point  somewhat 
below  the  origin  of  the  flaps.  Musculo- 
cutaneous flaps  are  made  by  transfixion, 
but  can  be  imitated  by  cutting  the  muscles         Amputation  by  lateral  flaps. 


748 


AMPUTATIONS, 


Fk;.  4S2. 


obliijuely  to  the  bone  in  the  lines  of  flap  incision.  The  latter  are  not 
popularor  to  be  recommended,  however,  as  they  provide  too  voluminous 
a  stump  and  divide  bloodvessels  obliquely,  or  may  notch  them  at  a  point 
above  where  the  ligature  will  be  applied. 

Teat.e's  method  of  amputating  consists  in  making  two  exactly  rect- 
angular musculo-cutaueous  flaps  :  a  long  one,  half  the  circumference  of 

the  limb  at  the  point  of  bone 
division  and  a  short  one,  half  the 
length  of  the  long  one,  or  one- 
fourth  the  circun)ference  of  the 
member.  In  the  typical  Teale 
operation  the  long  flap  is  taken 
from  the  anterior  surface  and 
forms  the  bone  covering,  while 
the  shorter  one  is  made  upon  the 
posterior  surface,  and  contains  the 
principal  bloodvessels.  Each  flaj) 
is  exactly  half  the  circumference 
of  the  limb  in  width.  But  prac- 
tically the  flaps  can  be  taken 
from  any  opposite  sides,  and  can 
be  altered  in  length  without  ma- 
terially interfering  with  the  ex- 
cellent stump  which  almost  inva- 
riably results.  INIany  surgeons  of  experience  omit  measurements  and 
approximate  the  dimensions  of  the  flap  by  the  eye,  but  usually  careful 
measurement  and  marking  out  with  indelible  pencil  or  nitrate  of  silver 
should  be  done  previous  to  operation.  Teale's  amputation  is  especially  fit 
for  the  forearm  and  leg,  but  may  be  adapted  to  the  arm  and  thigh  with 
success.  The  sole  objection  to  it  is  that  sometimes  more  of  the  member 
must  be  sacrificed  by  it  than  by  other  forms  of  amputation. 


Amputation  by  Teale's  metliod. 


Fig.  483. 


Teale's  amputation ;  completed  flaps.     (Teale.) 

Aftek-tueatment. — Happily,  in  these  days  ot  aseptic  wounds,  the 
after-treatment  of  amputation  wounds  has  become  almost  trivial,  unless 
by  accident  infection  has  taken  place.  Ordinarily,  even  largest  stumps 
need  not  be  redressed  for  from  two  w^eeks  (when  rubber  drains  should  be 
removed)  to  a  month.     They  should  simply  be  kept  quiet  and  somewhat 


AFFECTIONS    OF    STUMPS.  749 

elevated.  In  amputations  of  the  leg  or  thigh  the  joatient  should  be  kept 
in  bed  at  for  least  three  weeks,  but  in  removal  of  upper  extremities  he 
may  usually  be  up  much  earlier.  Antiseptic  dressings  should  be  kept 
applied  until  even  the  drain  sinuses  have  finally  closed. 

Affections  of  Stumps. — If  by  the  temperature  record,  pain,  etc.,  it 
becomes  apparent  that  the  wound  is  septic,  the  dressing  should  forthwith 
be  removed,  all  tension  relieved  by  dividing  sutures,  the  wound  cavity 
thoroughly  washed  out  with  antiseptic  solution,  perhaps  more  drain  tubes 
put  in,  and  the  dressing  reapplied,  or  the  extremity  put  under  antiseptic 
continuous  irrigation.  If  abscesses  form  they  should  at  once  be  opened, 
curetted,  and  drained.  Severe  infection  of  an  amputation  wound  would 
call  for  re-opening,  curetting,  washing  and  dressing  as  a  fresh  wound. 
Tissues  and  flaps  appearing  unharmed  at  the  time  of  operation  may  sub- 
sequently slough,  and  require  either  skin  grafting  or  re-amputation. 
Spreading  or  recurring  gangrene  imperatively  indicates  removal  of  the 
remaining  portion  of  the  extremity  at  either  its  junction  with  the  trunk  or 
at  a  point  well  beyond  the  affected  area.  Secondary  hemorrhage  in  asep- 
tic stumps  is  exceedingly  rare.  If  moderate  pressure  by  bandages  and 
pressure  upon  the  artery  of  supply  do  not  speedily  check  it,  the  wound 
must  be  opened  and  the  offendiug  vessel  tied. 

Bones  in  stumps  may  be  fractured  by  traumatism,  and  should  be  treated 
upon  the  general  principles  elsewhere  dwelt  upon,  or  the  fragment  may 
be  excised.      Osteomyelitis   continuing 

or  developing  in  the  bones  of  stumps  I^'ig.  484. 

should  be  treated  by  prompt  re-amputa-        ^^,^^.^'_^  _  ^  _^ 

tion  not  louver  than  through  the  first        -     '     '     '       ^  ~ 
joint  above. 

Aneurismal  tumors  or  varices  should 
be  treated  by  excision  of  the  vessel 
mass.  Bulbous  neuromata,  which  occa- 
sionally develop  upon  the  cut  nerve- 
ends  and  give  rise  to  intense  suffering, 
should  be  excised,  or,  this  failing,  the 
supplying  nerves  should  be  stretched  or 
cut  at  a  higher  point.  So  also  should 
be  treated  neuralgias  due  to  entangle- 
raeut  of  nerve  fibres  in  the  cicatrix. 

Occasionally  great  harm  is  done  to  a 

stump,    or   the    life  of  the   patient    even  Neuromata  in  stump.     Large  neur- 

endangered,  by  intense  muscular  twitch-     omatous  mass  at  a;   opposite  b  the 

ings,  or  the  presence  of  actual  chorea  in      tumors  are  more  defined.      (Miller  ) 

the  extremity.    Extension  of  the  stump, 

combined  with  tight  temporary  bandaging  of  the  muscles,  seda;tives,  anti- 
spasmodics, and  removal  of  irritating  causes  usually  suffice  for  perfect 
relief,  but  an  occasional  rare  case  will  baffle  all  remedial  efforts. 

Because  of  poor  surgery,  or  of  unavoidable  subsequent  sloughing,  the 
flaps  or  cicatricial  tissue  may  be  drawn  tightly  over  the  bone  end,  which 
may  even  come  directly  out,  producing  a  typical  form  of  what  is  called 
"  conical  stump."  Removal  of  more  bone,  or  re-amputation  at  a  higher 
point,  will  alone  answer  for  the  relief  of  this  condition. 

Chronic  ulcers,  eczema,  or  epitheliomata  may  develop  in  and  about  the 
cicatrix,  and  require  its  excision  or  a  re-amputation. 

As  in  all  aseptic  wounds,  tetanus  is  unheard  of  in  properly-treated 


750 


AMPUTATIONS. 


amputations.     Its  development  would  he  an  indication  of  infection  and 
demand  exploration  of  the  wound. 


Special  Amputations. 


Amputation  through  Shoulder-Joint. 

Hemorrhage  is  prevented  by  a  rublier  band  tourniquet  passed  through 
the  axilla  acros.<  the  spine  of  the  scapula  and  tied  tightly  dcnvn  upon  the 
acromial  end  of  the  clavicle;  by  pressure  of  the  thunil)  or  a  padded  key  in 
the  post-clavicular  fossa,  therel)y  compressing  the  subclavian  artery  upon 
the  tirst  rib  ;  or.  perhaps  best,  by  having  an  assistant  compress  the  axillary 
vessel  in  the  flap  before  it  is  finally  severed.  A  primary  incision  is  made 
by  splitting  the  deltoid  into  equal  parts  from  its  origin  to  insertion,  and 

Fig.  485. 


Application  of  Esmarch's  tourniquet  in  amputation  thiougli  shoulder-joint.     (Smith.) 


carried  down  to  the  bone  throughout ;  that  is,  from  the  acromion  process 
of  the  scapula  directly  downward  for  about  three  inches.  Subsequent  in- 
cisions are  carried  from  the  base  of  this  one  in  a  slightly  obli(jue  and  down- 
ward direction  to  the  anterior  and  posterior  borders  of  the  axilla,  being 
careful  not  to  prolong  either  incision  so  far  as  to  threaten  the  axillary 
artery.  The  two  lateral  flaps  thus  made  are  then  dissected  up  and  freed 
from  the  bone  ;  the  capsule  is  widely  incised  ;  the  long  head  of  the  biceps 
divided  close  to  its  insertion  ;  the  attachments  of  the  humeral  tuberosi- 
ties divided  after  being  made  tense  by  inward  and  outward  rotation  of 
the  arm,  and  the  bjne  exarticulated  by  drawing  the  elbow  across  the 
chest  toward  the  opposite  side.  A  trustworthy  assistant  now  compresses 
the  axillary  artery  high  up  in  the  flap,  the  remaining  bridge  of  tissue 
containing  the  vessel  is  divided  at  a  lower  point,  and  the  extremity  re- 
moved. With  perhaps  more  certainty  of  avoiding  loss  of  blood,  particu- 
larly in  absence  of  a  competent  assistant,  a  tourniquet  can  be  applied 
to  the  arm  high  up  and  a  circular  amputation  done  at  the  insertion  of  the 
deltoid  muscle.  The  arteries  are  then  secured,  and  an  incision  made 
slitting  the  deltoid  as  before  described,  through  which  the  remaining  por- 
tion of  the  bone  is  excised.  If  the  tissues  of  the  axilla  are  much  injured, 
a  single  large  flap  can  be  taken  from  the  outer  aspect  of  the  member. 


SPECIAL    AMPUTATIO^■  S. 


751 


including  the  entire  deltoid,  or,  vice  versa,  a  flap  from  the  inner  aspect  can 
be  made  to  cover  in  the  wound. 


Fig.  4Sfi. 


Fig.  487. 


Amputation  through  shoulder-joiut.  Lines 


Amputation   through   shoulder-joint. 


of    incision    (usual    or    oval    method).         Lines    of    incision    for.  modified   oval 


(Ltston.) 


method.     (Smith.) 


Fig.  4S8. 


Section  through  the  middle  of  right  arm.  (Heath,  from  Beraud.)  1,  biceps:  2, 
cei^halic  vein;  3,  brachial  vessels j  4,  musculo-cutaneous  nerve:  5,  median  nerve:  6, 
brachialis  anticus;  7,  ulnar  nerve,-  8,  musculo-spiral  nerve;  9,  basilic  vein  with  internal 
cutaneous  nerves :  10,  superior  ijrofunda  vessels:  11,  inferior  profunda  vessels ;  12,  triceps 

with  iutra-muscular  aponeurosis. 


752  AMPUTATIONS. 


Amj>u(ation  of  (he  Ann. 

Amputation  of  tlie  arm  can  be  acconiplLslied  by  double  flaps  from  any 
opposite  aspects  of  the  member,  or  by  the  single  flap,  the  circular,  or  Teale 
methods.  The  deltoid  attachments  should  be  retained  if  possible  in  high 
amputations.  Operation  by  internal  and  external  flaps,  the  former  a 
little  longer  than  the  latter,  or  the  formal  Teale,  are  usually  more  satis- 
factory. The  member  should  be  removed  at  as  low  a  point  as  is  com- 
patible with  vitality  of  the  flaps. 

Amputation  through  the  Elboic-joint. 

This  is  best  done  by  antero-posterior  rectangular  or  elliptical  flaps,  tiie 
resulting  stump  being  a  most  useful  one,  but  nothing  to  compare  with 
that  of  removal  a  short  distance  below  the  joint,  whereby  the  insertions 
of  the  biceps  and  triceps  muscles  are  preserved.  The  forearm  being 
supinated,  incisions  are  made  from  the  cond3'les  of  the  humerus  down  to 
and  along  the  radius  and  ulna  respectively  for  a  distance  of  about  four 
inches,  and  their  lower  extremities  are  connected  anteriorly  by  a  third 
transverse  incision.  The  fleshy  flap  included  between  the  incisions  is  dis- 
sected up,  keeping  close  to  the  bones,  until  the  level  of  the  condyles  is 
reached.  Another  incision  is  now  made  directly  across  the  back  of  the 
articulation  down  to  the  bone  connecting  with  the  primary  incision  on 
each  side.  The  knife  is  then  passed  between  the  head  of  the  radius  and 
the  humerus,  and  down  through  the  joint,  dividing  the  lateral  ligaments; 
after  which  the  olecranon  is  either  detached  from  its  biceps  attachments, 
or  else  sawn  through  from  above  downward  directly  above  the  coronoid 
process.  If  the  latter  portion  of  bone  is  uninjured  it  is  better  to  allow  it 
to  remain,  as  thereby  the  triceps  insertion  is  preserved  and  a  more  service- 
able stump  secured.  The  ends  of  the  flap  are  first  sutured  and  then  the 
sides. 

Amputation  of  the  Forearm. 

This  may  be  done  by  the  Teale  or  circular  methods  or  by  any  other 
variety  of  flaps.  If  no  extra  length  is  thereby  sacrificed,  the  Teale  opera- 
tion should  hold  preference  over  all  others.  The  upper  portion  of  the 
lower  third  of  the  member  would  be  the  point  of  election.  Any  pro- 
jecting tendon  ends  should  be  well  drawn  down  and  cut  off".  Care  must 
be  taken  to  ligate  securely  the  inter-osseous  artery. 

Amputation  through  the  Wrid-joint. 

This  is  performed  by  securing  a  large  fleshy  flap  from  the  palm  and  a 
smaller  one  from  the  dorsum  of  the  hand.  These  may  be  either  rectan- 
gular or  oval,  but  the  nature  of  injury  may  compel  the  use  of  other  shapes 
or  kind  of  flaps.  Here,  likewise,  tendon  ends  must  be  drawn  down  and 
cut  off". 

Inter-carpal  and  Carpo-metacarpal  Amputations. 

Inter-carpal  and  carpo-metacarpal  amputations  are  never  performed, 
as  they  make  useless  and  impedimental  stumps,  to  which  prothetic  appa- 
ratus cannot  be  adjusted. 


SPECIAL    AMPUTATIONS.  753 


Amputation  of  the  Sand. 

Amputation  of  the  hand  through  the  metacarpal  bones  may  sometimes 
be  done  and  a  very  useful  stump  secured.  Oval  or  rectangular  antero- 
posterior flaps  should  be  employed.  Amputations  through  one,  two,  or 
three  metacarpals  are  done  in  a  similar  manner. 

Fig.  489. 


1+16  17       15     13 

Section  through  the  middle  of  the  right  forearm.  (Heath,  altered  from  Beraud.) 
1,  anterior  interosseous  vessels  and  nerve;  2,  radial  vessels  and  nerve;  3^  pronator 
teres;  4,  supinator  longus ;  5,  flexor  carpi  radialis;  6,  supinator  brevis;  7,  flexor  suh- 
limis  digitorum:  8,  exteusores  carpi  radialis  longior  and  brevior;  9,  flexor  carpi  ulnaris  ; 
10,  extensor  ossis  metacarpi  pollicis;  11,  ulnar  vessels  and  nerve;  12,  extensor  communis 
digitorum;  13,  flexor  profundus  digitorum ;  14,  extensor  carpi  ulnaris ;  15,  median  nerve; 
16,  posterior  interosseous  vessels  and  nerve:  17,  extensor  secundi  internodii  pollicis. 

Amputation  through  the  Metaemyal  Phalangeal  Articidation. 

Four  fingers  can  be  removed  by  antero-posterior  flaps ;  two  by  oval 
incision,  entering  the  knife  half  an  inch  above  the  knuckle  and  cutting 
downward  around  one  side  of  one  finger  across  the  palm  beneath  both 
and  up  the  opposite  side  of  the  second  finger  to  the  point  of  origin,  and 
one  finger  by  the  same  shape  of  incision,  but  limited  to  a  single  digit.  If 
strength  of  hand  is  desired  the  heads  of  the  metacarpal  bones  should  not 
be  disturbed,  but  if  appearances  alone  are  to  be  considered  they  should 
be  cut  off"  by  cutting  pliers. 

Amputation  of  the  Thumb. 

This  is  effected  by  an  oval  incision.  The  knife  is  entered  just  above  the 
articulation  and  carried  down  along  the  upper  surface  of  the  metacarpal 
bone  until  its  centre  is  reached,  when  it  diverges,  encircles  the  extremity 

48 


754 


AMPUTATIONS, 


just  above  the  first  inter-])halangeal  joint,  and  again  joins  tlie  primary 
incision.  Amputation  of  the  thumb  through  its  metacari)al  bone  may 
also  be  made  by  oval  incision,  the  jioint  of  the  oval  being  directly  over 


Fig.  490. 


Fig.  41U. 


Removal  of  head  of  metacarpal  bone.      Amputation  of  thumb  with  its  metacarpal  bone. 
(Driitt.)  Line  of  incision.     (Druitt.) 

the  bone  just  above  the  point  where  it  is  to  be  divided,  which  latter  is 
accomplished  by  strong  cutting  pliers.  Amputation  through  the  cor- 
responding bone  or  joint  of  the  little  finger  is  executed  by  analogous 
procedures  at  its  carpo-metacarpal  junction. 

Avxputaiion  of  Phalanges  of  Hand. 

This  is  done  either  through  the  bone  by  antero-posterior  or  other  incis- 
ions, or  through  inter-phalangeal  joints.  In  doing  the  latter  operation  it 
is  well  to  make  a  short  anterior  flap  and  a  large  posterior  one  from  the 
belly  of  the  digit.  The  joint  can  always  be  opened  readily  by  flexini; 
the  finger  and  pressing  the  knife  just  below  the  head  of  the  proximal 
bone.  Occasionally  no  anterior  flap  is  made,  but  the  knife  is  at  once 
pressed  through  the  joint,  and  a  lai'ge  posterior  flap  cut  as  it  is  withdrawn 
after  pa-ssing  through  the  joint.  Ligatures  are  never  required  in  finger 
amputations ;  sutures  including  the  vessels  can  be  made  to  control  all 
hemorrhage.  Drainage,  as  a  rule,  is  not  necessary.  An  India  rubber 
umbrella-ring  answers  well  as  a  tourniquet. 


Amputation  through  the  Hip-joint. 

This  is  a  dangerous  and  formidable  operation,  owing  to  the  great 
primary  and  subsequent  shock,  which  an  operation  so  near  the  trunk 
dividing  such  huge  vessels  and  nerves  must  necessarily  involve. 

The  death  rate  of  tertiary  operations  is  high;  that  of  primary  opera- 
tions exceedingly  so.  The  limb  having  been  rendered  avascular  by  ele- 
vation or  rubber  bandage,  infinite  care  must  be  observed  to  prevent  undue 
hemorrhage.  This  can  be  done  (1)  by  digital  pressure  upon  the  femoral 
artery  as  it  passes  under  Poupart's  ligament;  (2)  by  compression  of  the 
corresponding  iliac  artery  against  the  ilium  by  the  fingers  of  a  small  hand 
introduced  into  the  rectum  ;  or  (3),  by  preliminary  ligation  of  the  femoral 
just  beneath  Poupart's  ligament.    Abdominal  tourniquets  are  unnecessary 


SPECIAL    AMPUTATIONS. 


755 


and  undesirable.  The  above  methods  of  controlling  hemorrhage  apply- 
only  to  the  older  methods  of  making  large  antero-posterior  flaps  by  trans- 
fixion or  otherwise.  The  nature  of  injury  or  disease  may'  occasionally 
render  amputation  by  those  methods  necessary.  The  scrotum  being  held 
out  of  the  way,  the  sound  leg  well  abducted,  and  the  diseased  thigh 
having  been  slightly  bent  to  slacken  the  anterior  muscles  and  abducted,  an 

Fig.  492. 


Amputation  through  hip-joint  by  long  anterior  and  short  posterior  flaps.  A.  The 
femoral  and  profunda  vessels,  with  branches  of  anterior  crural  nerve.  B.  The  great 
sciatic  nerve  and  its  companion  artery  and  branch.  C  Muscular  mass  from  tuber 
isehii  and  obturator  externus  muscle,  with  large  branches  from  profunda  and  gluteal 
arteries  on  either  side.  D.  The  psoas  and  other  muscles  immediately  in  front  of  the 
joint.     (Holmes.) 


eighth-inch  knife  is  entered  just  above  the  centre  of  the  space  between  the 
anterior  superior  spine  of  the  ilium  and  the  great  trochanter;  is  pushed 
obliquely  downward  and  inward  until  the  joint  is  touched  ;  the  handle  is 
then  depressed  until  the  knife  point  slips  across  the  joint  (thereby  opening 
up  the  capsule),  when  it  is  raised  again  and  the  point  pushed  on  until  it 
emerges  just  in  advance  of  the  tuber  isehii.  By  a  downward,  and, 
finally,  outward  sawing  motion,  a  large  anterior  flap  is  formed  as  the 
knife  is  brought  to  the  surface.  Just  before  the  outward  stroke  is  made, 
an  assistant  controls  the  femoral  by  grasping  it  firmly  in  the  upper  por- 
tion of  the  flap.  This  vessel  is  then  securely  ligated  ;  the  flap  is  held  up, 
and,  the  thigh  being  rotated  inward,  the  muscular  attachments  of  the  great 
trochanter  are  divided.  The  limb  is  now  hyper-extended  and  adducted, 
thereby  accomplishing  exarticulation,  while  the  knife  continues  its  down- 
ward course  and  cuts  a  fleshy  posterior  flap.  Or,  a  large  anterior  cutane- 
ous flap  may  be  cut  from  without  inward  in  the  same  lines  as  above,  the 
vessels  isolated  and  tied  in  continuity,  and  then  a  division  of  the  muscles 
made  down  to  and  opening  the  joint,  but  below  the  point  of  ligation ;  the 
subsequent  steps  being  identical  with  the  first  described  method.  But  for 
chronic  cases  where  the  parts  are  much  wasted,  or  where  every  particle 


75G 


A  MPUTATIONS, 


of  blood  is  of  great  importance,  a  more  recent  procedure  (Forneaux- 
Jordan  method)  is  by  far  the  best.  This  may  be  performed  in  several 
ways: 

1.  A  tourniquet  is  ])lncod  upon  the  highest  situation  of  the  thigh  pos- 
sible. A  circular  division  of  integument  and  muscles  to  the  bone  is  then 
made  by  a  single  sweep  immediately  below  the  tourniquet,  the  bone 
divided,  and  all  vessels  secured  as  in  a  thigh  amputation.  These  having 
been  ligated,  a  second  incision  is  made  from  just  above  the  great 
trochanter  downward  until  it  runs  at  a  right  angle  into  the  first.  The 
attachments  of  the  trochanter  are  divided,  the  joint  opened,  the  remainder 
of  the  femur  carefully  dissected  out,  and  the  flaps  sutured. 

2.  The  vessels  can  be  ligated  after  the  circular  incision  without  sawing 
the  bone,  which  is  removed  entire  through  the  second  incision. 

3.  The  operation  may  be  done  by  oval  or  racket-shaped  incision,  pre- 
cisely the  same  as  amputation  of  the  shoulder  is  performed.  The  down- 
ward straight  incision  is  made  from  the  trochanter,  and  from  its  lower 
extremity  branches  diverge  forward  and  backward,  concave  downward, 
terminating  just  before  reaching  the  femoral  vessels.  The  flaps  thus 
formed  are  separated  from  bone,  and  exarticulation  is  accomplished. 
Finally,  after  an  assistant  grasps  the  vessel  in  it,  the  remaining  bridge  of 
integument  and  tissue  is  divided  and  the  vessels  ligated.  No  tourniquet 
is  here  required. 

The  hip  may  also  be  exarticulated  by  simple  large  antero-posterior 
musculo-cutaneous  flaps  cut  from  above  obliquely  downward  and  upward 
toward  the  joint.  In  this  case  the  posterior  flap  should  be  made  first, 
and  its  ves.sels  secured  by  forceps  or  ligatures  before  the  anterior  flap  is 
commenced.  A  large,  flat,  hot  sponge  pressed  upon  the  cut  surface  may 
answer  temporarily  for  this  purpose,  however. 


Fig.  4'J3. 


Section  of  the  right  thigh  at  the  apex  of  Scarpa's  triangle:  1,  profunda  vessels;  2, 
adductor  longus;  3,  femoral  vessels;  4,  superficial  obturator  nerve;  5,  sartorius;  6, 
gracilis;  7,  external  cutaneous  nerve;  8,  pectineus;  9,  rectus  femoris;  10,  adductor 
brevis;  11,  anterior  crural  nerve;  12,  deep  obturator  nerve:  13,  external  circumflex 
vessels;  14,  adductor  magnus;  15,  tensor  vagina  femoris;  16,  semi-membranosus; 
17,  vastus  internus  and  crureus;  19,  semi-tendinosus;  19,  vastus  externus;  20,  small 
Sciatic  nerve:   21,  biceps  femoris ;  22,  great  sciatic  nerve.     (Heath.) 


SPECIAL    AMPUTATIONS. 


757 


Amputation  of  the   Thigh. 

This  may  be  accomplished  by  ordinary  flaps,  antero-posterior  or  lateral, 
or  by  the  typical  or  modified  Teale  method.  The  latter  is  best  when  it 
does  not  sacrifice  length  unduly. 


Amputation  through  the  Knee-joint. 

This  makes  an  excellent  and  serviceable  stump.     It  may  be  done 
large  anterior  flap,  including  the  patella,  and  a  short  posterior  one 
the    fleshy   portion   of    the    upper    calf.      The 
former  is  cut   from  above  doAvnward  to  bone,  Fis-  494. 

and  dissected  up  above  the  condyles  of  the 
femur.  The  knife  is  then  sunk  through  the 
joint  as  it  is  held  flexed,  and  the  posterior  flap 
is  made  as  it  is  brought  to  the  surface  through 
the  subjacent  tissues.  The  operation  may  also 
be  performed  by  lateral,  single  anterior,  or  single 
posterior  flaps,  but,  as  a  rule,  not  with  so  great 
success.  If  the  patella  is  diseased  or  badly  in- 
jured, it  should  be  dissected  from  the  flap.  If 
the  uninjured  integument  is  not  suflicient  to 
cover  the  condyles,  more  or  less  of  the  latter 
must  be  sawn  off",  and,  if  the  patella  is  left  in, 
its  under  surface  should  be  removed  until  can- 
cellous structure  is  exposed,  when  it  may  be 
nailed  or  sutured  to  the  sawn  femoral  end,  and 
there  expected  to  unite.  If  in  so  doing  the 
quadriceps  tendon  is  made  taut,  it  should  be 
divided  from  the  under  surface  of  the  flap. 
This  may  occasionally  be  necessary  in  any  case. 


by  a 
from 


Amputation  through  knee- 
joint  by  long  anterior  flap. 

(Erichsex.) 


Amjndation  of  the  Leg. 

This  should  never  be  performed  below  the 
centre  of  the  limb,  nor  in  close  proximity  to  the 
knee-joint ;  such  removals  result  in  worse  than 
useless  stumps  upon  which  prothetic  apparatus 
cannot  be  placed.  The  point  of  election  is  the  junction  of  the  upper  and 
middle  thirds.  The  Teale  method  here  finds  an  ideal  application  and  re- 
sult, but  good  results  can  also  be  obtained  by  almost  any  variety  or  com- 
bination of  flaps.  After  sawing  the  bones  the  sharp  upper  edge  of  the  tibia 
should  be  sawn  off"  obliquely,  that  it  may  not  subsequently  press  upon  the, 
at  that  point,  necessarily  thin  flap. 


Amputation  through  the  Ankle-joint. 

This  is  not  favorably  regarded  by  most  surgeons,  because  of  the  numer- 
ous failures  caused  by  sloughing  of  flaps.  No  amputation  at  this  point 
is  justifiable  unless  a  well-nourished  single  flap  from  the  heel  (Syme's 
method)  can  be  obtained.  And  it  is  the  death  of  this  very  flap  which 
has  required  so  many  re-amputations  in  this  situation  and  brought  the 


758 


AMPUTATIONS. 


operation  into  discredit.     But  a  more  clear  understanding  of  the  nutrient 
supply  of  the  heel  and  its  surroundings  luus  again  revived  this  operation 


Fk;.  495. 


A  section  of  the  right  leg  in  the  upper  third.  (Heath,  from  Beraud.)  1.  Tibialis  pos- 
ticus; 2.  Tibialis  anticus;  3.  Flexor  longus  digitorum ;  4.  Extensor  longus  digitorum ; 
5.  Internal  saphenous  vein  ;  6.  Anterior  tibial  vessels  and  nerve;  7.  Tendon  of  Plantaris; 
8.  Peroneus  longus  :  10.  Flexor  longus  pollicis ;  11.  External  saphenous  vein  and  nerve; 
12.  Soleus  with  fibrous  intersection  :  13.  Peroneal  vessels;  14.  Gastrocnemius  (outer  half  j ; 
15.  Communicans  peronei  nerve. 

which,  when  successful,  is  eminently  so.     The  foot  is  flexed  to  a  right 
angle,  and  from  the  centre  of  the  internal  malleolus  an  incision  is  carried 

Fig.  490. 


Amputation  through  ankle-joint.     Syme's  method.     (Skey.) 

down  to  the  bone  directly  across  the  sole  to  a  point  over  one-fourth  of 
an  inch  in  advance  of  the  external  malleolus.     The  extremities  of  this 


SPECIAL    AMPUTATIONS. 


769 


incision  are  then  connected  by  a  second,  also  carried  down  to  the  bone, 
arching  sharply  upward  across  the  dorsal  surface  of  the  ankle.  Next  the 
foot  is  forcibly  flexed  and  the  ankle-joint  opened  through  the  upper  incis- 
ion. The  lateral  ligaments  are  divided  and,  the  foot  being  still  flexed, 
the  attachments  of  the  astragalus  and  calcaneum  are  carefully  dissected 
off,  the  point  and  edge  of  the  knife  being  kept  toward  the  bones.  Espe- 
cially must  caution  be  observed  in  dissecting  about  the  lesser  tuberosity 
of  the  OS  calcis  and  inner  portions  of  the  ankle,  that  the  vessels  there 
situated,  and  upon  which  the  life  of  the  flap  mostly  depends,  may  not 
be  injured.  Finally,  the  dissection  reaches  the  insertion  of  the  tendo 
Achillis.  This  is  separated  and  the  removal  completed.  The  malleoli 
and  a  thin  slice  of  articular  cartilage  are  then  sawn  from  the  tibia  and 
fibula,  and,  after  tendon  ends  are  retracted,  the  flaps  are  sutured. 

Pirogoff's  amputation  differs  from  the  above  in  that,  by  this  method,  a 
portion  of  the  calcaneum  is  allowed  to  remain  and  is  brought  into  contact 
with  the  sawn  ends  of  the  tibia  and  fibula,  where  it  usually  unites  by 
bony  union  and  makes  a  capital  stump.  The  incisions  are  as  above 
described,  except  that  the  lower  one  in  crossing  the  sole  is  carried  from 
one-half  to  three-quarters  of  an  inch  nearer  the  tip  of  the  heel,  nor  by 


Fig.  497. 


Diagram  of  cutaneous  incision  on  outer  side  (A),  and  lines  of  section  of  the  bones  (B) 
in  Pirogoff's  amputation.     (Stimson.) 

the  same  distance  does  the  dorsal  incision  ascend  the  ankle.  Each  flap 
having  been  dissected  up  about  half  an  inch  the  joint  is  opened  from 
above.  The  foot  being  strongly  flexed  the  astragalus  is  shot  forward 
from  between  the  malleoli.  Behind  the  astragalus  is  then  inserted  a 
narrow-bladed  saw  and  the  os  calcis  sawn  through  in  a  direction  obliquely 
downward  and  forward.  The  soft  parts  are  then  dissected  from  the  mal- 
leoli, and  so  much  of  the  latter  is  removed  as  to  expose  the  cancellar 
tissue  of  both  leg  bones.  The  flaps  are  then  sutured,  bringing  the  two  sawn 
surfaces  in  contact,  where  they  are  secured  by  a  nail  or  two  driven  through 
the  flaps.  Bony  union  is  usual.  Possibly  the  tendo  Achillis  may  require 
division.  Pirogoff's  method  affords  a  better,  more  useful  and  solid  stump, 
and  with  less  shortening  of  the  limb  and  liability  of  reamputation  than 
when  the  Syme  operation  is  employed.  A  good  result,  including  ankle- 
joint  motion,  can  also  be  obtained  by  leaving  the  astragalus  in  situ,  sawing 
off  its  under  surface  and  bringing  the  divided  portion  of  the  calcaneum 


760 


AMPUTATIONS. 


into  contact  with  it.     Syme's  method  may  he  modified  so  as  to  leave  the 
astragalus  in  position. 

Fig.  498. 


Pirogoff's  amputation.     Lines  of  incision.     (Euichsex.) 


Amputation  through  the  Medio-tarsal  Joint.     {Chopart's.) 

An  incision  is  made  across  the  dorsum  of  the  foot,  convex  downward, 
from  midway  between  the  external  malleolus  and  the  tuberosity  of  the 
fifth  metatarsal  bone  to  a  point  just  behind  the  prominence  of  the  scaphoid. 
The  extremities  of  this  incision  are  carried  vertically  downward  well  into 


Fig.  499. 


Fig.  500. 


Stump  after  PirogofF  araj)utation. 
(Erichsex.) 


Amputation  through  medio-tarsal  joint. 
(Bryant.) 


the  ball  of  the  foot,  where  these  incisions  are  connected  by  a  fourth 
crossing  the  plantar  surface.  A  fleshy  plantar  flap  is  then  dissected  up  ; 
the  foot  forcibly  pressed  down,  and  disarticulation  effected  at  the  medio- 
tarsal  junction.  Division  of  the  tendo  Achillis  to  prevent  sub.sequent 
contraction  of  the  flaps  is  expedient.  The  scaphoid  bone  is  occasionally, 
by  accident,  left  behind,  but  gives  rise  to  no  inconvenience. 


SPECIAL    AMPUTATIONS.  761 


Amjndation  through  the  Tarso-metatarsal  Joint.     (Lisfrane's.) 

In  this  operation  a  transverse  dorsal  incision,  convex  downward,  runs 
from  the  tuberosity  of  the  fifth  metatarsal  bone.  A  plantar  flap  is  made 
as  in  medio-tarsal  amputation.  The  foot  being  pressed  down,  the  three 
outer  and  the  first  metatarsal  bones  are  separated  from  the  tarsus.  Then 
the  second  metatarsal  (which  projects  into  the  sjoace  between  the  internal 

Fig.  501. 


Amputation  through  the  tarso-metatarsal  joint.     (Sket 


and  external  cuneiform  bones)  is  likewise  separated  by  driving  the  point 
of  the  knife  between  it  and  the  internal  cuneiform,  and,  the  foot  being 
forcibly  everted,  carrying  it  around  the  joint.  Or,  to  avoid  this  latter 
difficulty,  the  end  of  the  second  may  be  sawn  off  and  left  in  sitti  after 
the  other  metatarsals  have  been  exarticulated  (Hey's  amputation). 

Amputation  through  the  Metatarsus. 

Amputation  through  the  metatarsus,  or  metatarso-phalangeal  junction, 
as  a  whole,  is  accomplished  by  taking  a  short  flap  from  above  and  a  longer 
fleshy  one  from  the  ball  of  the  foot. 

Amputations  of  the  great  or  small  toes  at  their  metatarso-tarsal  articu- 
lation, also  of  one  or  more  toes  at  the  metatarso-phalangeal  junctions,  are 
accomplished  by  the  same  racket-shaped  incision  method  by  which  analo- 
gous portions  of  the  hand  are  removed.  Amputations  through  the  inler- 
phalangeal  toe-joints  is  performed  by  antero  posterior  or  lateral  square  or 
oval  flaps.  Amputation  of  toe  phalanges  should  always  be  done  through 
a  joint. 


CHAPTER     XXYII. 

DISEASES   OF   THE   MAMMARY  GLANDS. 
Neuroses. 
Mammary  Neuralgia. 

Neuralgia  of  the  mammary  glands  is  found  especially  in  young 
women,  and  is  often  associated  with  some  ovarian  or  uterine  difficulty. 
Hypenesthesia  is  often  excessive,  so  that  the  mere  contact  of  the  clothing 
gives  rise  to  great  pain.  A  similar  neuralgic  condition  is  at  times 
found  as  an  accompaniment  of  small  benign  tumors  of  the  breast  or 
of  chronic  mammary  inflammation.  It  is  often  difficult  to  correct 
this  condition  because  of  the  nervous  element  involved.  If  the  surgeon 
can  discover  the  cause  of  the  nervous  strain  and  remove  it  the  disease 
will  disappear  entirely.  The  fear  felt  by  the  patient  that  the  condition 
is  one  of  malignant  disease  must  be  dispelled,  as  it  has  a  tendency  to 
increase  the  pain.  It  should  be  recollected  also  that  this  affection,  which 
is  one  of  no  vital  importance,  is  more  painful  than  are  malignant  growths 
in  their  early  stages.  At  times  there  is  a  slight  serous  or  blood-stained 
discharge  from  the  nipple  when  the  mastodynia  or  neuralgia  of  the 
breast  accompanies  a  localized  chronic  inflammation. 

Treatment. — The  treatment  consists  in  assuring  the  patient  of  the 
innocent  character  of  the  disease ;  in  distracting  attention  from  the  mam- 
mary region  ;  in  relieving  the  source  of  the  nervous  wear  and  tear ;  and 
in  giving  mental  occupation  of  an  agreeable  nature.  Valerianate  of 
zinc,  iron  preparations,  and  other  tonics  are  the  remedies  indicated  ;  in 
fact,  the  line  of  treatment  is  that  to  be  followed  in  cases  of  hysteria.  If 
there  be  any  small  inflammatory  nodules  within  the  breast  it  is  proper  to 
remove  them  if  the  patient's  anxiety  is  great  enough  to  warrant  such  a 
slight  operative  procedure.  If  the  surgeon  is  in  doubt  as  to  the  charac- 
ter of  these  hardened  tissues,  operation  is  valuable  by  enabling  him  to 
clear  up  the  diagnosis.  The  question  of  malignancy  can  then  be  defi- 
nitely settled  by  the  microscope. 

Inflammation  of  the  Breast. 

Pathology. — Inflammation  of  the  mammary  glands,  called  mastitis  or 
mammitis,  may  be  acute  or  chronic.  In  the  former  condition,  suppuration, 
causing  what  is  termed  mammary  abscess,  may  occur.  This  is  very  unu- 
sual, however,  excepting  during  lactation.  The  so-called  cold  abscess,  due 
to  the  tubercle  bacillus,  is  rare,  but  may  occur.  Acute  mastitis  arises  occa- 
sionally as  a  complication  of  mumps,  just  as  in  the  male  we  find  orchitis 
arising  secondary  to  that  inflammation  of  the  parotid  gland.  Acute  inflam- 
mation of  the  breast,  not  connected  with  pregnancy  and  lactation,  is 
similar  to  the  condition  occurring  as  a  complication  of  parotitis,  and  needs 
no  special  mention.     Puerpei'al  mastitis  occurs  more  commonly  in  primi- 


INFLAMMATION    OF    THE    BREAST.  763 

parse,  and  during  the  first  three  or  four  weeks  of  nursing,  although  it 
may  occur  at  the  end  of  many  months  of  suckling.  It  is  not  usual  in 
mothers  who  bring  up  their  children  by  artificial  feeding.  The  causes 
are  over-distention  of  the  milk-ducts  because  there  is  more  milk  secreted 
than  can  be  drawn  from  the  glands  by  the  child,  and  sore  nipples.  In 
instances  of  fissured  or  otherwise  irritated  nipples,  the  child  is  unable 
freely  to  empty  the  breast,  and  by  its  efforts  causes  still  further  irritation 
of  the  inflamed  tissue.  The  inflammation  so  caused  at  the  nipple  travels 
along  the  lymphatics  into  the  interior  of  the  breast,  and  adds,  therefore, 
its  irritative  influence  to  that  due  to  distention  of  the  milk-ducts  from 
retained  lacteal  secretion.  The  probability  of  microbic  infection  through 
fissures  of  the  nipple,  especially  when  absolute  cleanliness  is  not  observed, 
is  easily  understood.  It  is  probable  that  freely  v/ashing  the  surface  after 
nursing  with  some  form  of  non-poisonous  antiseptic  would  prevent  many 
cases  of  mastitis. 

Symptoms. — Acute  mammitis  begins,  as  a  rule,  with  a  chilly  sensation, 
fever,  headache,  and  local  soreness  of  the  breast,  followed  by  heavy,  aching 
sensation,  with  throbbing.  Upoji  manipulation,  the  organ  feels  hard 
and  knotty  in  spots,  because  inflammation  usually  affects  a  few,  not 
all,  of  the  lobules  of  the  gland.  As  the  disease  progresses  the  whole 
breast  becomes  swollen  and  hard,  and  the  skin  tense,  shining,  and  livid. 
If  suppuration  occurs  it  is  usually  preceded  by  a  chill,  after  which  the 
skin  becomes  oedematous.  Soon  there  is  evidence  of  pointing,  and  the  pus 
is  finally  evacuated  spontaneously  if  the  abscess  is  not  opened  by  the  sur- 
geon's knife. 

Treatment. — The  treatment  should  be  physical  and  functional  rest. 
The  former  is  obtained  by  keeping  the  patient  quiet,  with  the  arm  sup- 
ported in  a  sling,  and  the  breast  held  up  against  the  thorax  by  a  closely 
fitting  bandage.  Functional  rest  is  obtained,  if  the  case  is  a  puerperal 
one,  by  preventing  the  child  nursing.  It  is  important  that  neither  breast 
be  used  for  suckling.  If  the  secretion  of  milk  continues  and  causes  pain 
by  distention,  it  is  necessary  to  empty  both  glands  by  means  of  a  breast- 
pump  carefully  applied.  Leeches  may  be  used  in  persons  of  vigorous 
health,  and  should  be  applied  below  the  breast  rather  than  above  it. 
Purgatives  and  antiphlogistic  remedies  are  indicated  in  cases  of  sthenic 
type,  but  if  the  patient  is  debilitated,  tonic  rather  than  depressing  reme- 
dies should  be  prescribed.  Hot-water  fomentations,  applied  by  means  of 
a  conical  sponge  laid  over  the  breast  several  times  a  day,  will  often  be  a 
great  comfort  to  the  patient.  An  antiseptic  dressing  covered  with  rubber 
tissue  to  prevent  evaporation,  makes  a  good  emollient  dressing.  The  ex- 
tract of  belladonna  made  into  a  paste  with  a  little  water,  and  spread  upon 
the  surface  of  the  breast,  lessens  the  pain  and  may  aid  in  diminishing  the 
secretion  of  milk.  Lotions  of  lead-water  and  laudanum  are  at  times 
serviceable.  Some  surgeons  believe  that  the  application  of  ice-bags  is 
good  practice.  In  some  cases  inflammation  subsides  by  resolution,  and 
after  two  weeks'  time  the  patient  may  resume  nursing.  If  suppuration 
occurs,  free  incision  and  curetting  must  be  adopted  at  a  very  early  period. 
This  will  be  discussed  under  abscesses  of  the  breast.  Acute  mastitis  may 
run  on  to  a  stage  of  chronic  inflammation,  which  must  be  managed  in  the 
same  manner  as  cases  which  assume  a  chronic  type  from  the  beginning. 


7()4  DISEASES    OF    THE     MAMMARY    GLANDS. 


Chronic  Inflammation  of  the  Breast. 

Pathology  and  Symptoms. — Chronic  inflammation  of  the  breast 
usually  attacks  only  one,  two,  or  three  lobules  of  the  gland  and  exhibits 
itself  as  a  hard,  irregular  mass  accompanied  by  a  moderate  degree  of 
pain.  The  process  is  a  sort  of  cirrhosis.  The  inflammatory  ])rocess  in- 
volves the  connective  tissue,  which  becomes  increased  in  amount  and  com- 
presses the  glandular  structure  of  the  breast  until  it  becomes  more  or  less 
atrophied.  Since  the  whole  gland  is  not  aflected,  there  is  a  certain  resem- 
blance between  this  lobular  mastitis  and  carcinoma,  because  in  each  case 
there  is  no  sharp  outline  felt  between  the  growth  and  the  normal  gland, 
and  because  the  two  conditions  are  most  common  about  the  menopause. 
The  points  of  diagnosis  are  that  the  inflammatory  induration  is  not  as 
hard  as  carcinoma;  the  integument  is  not  adherent  to  the  mass  nor 
dimpled  by  it.  Moreover,  carcinoma  is  apt  to  attack  single  portions  of 
the  breast,  whereas  inflammatory  involvement  of  two  or  three  lobules  is 
not  uncommon.  Again,  the  inflammatory  condition  may  be  found  in 
both  breasts  at  the  same  time  ;  this  condition  is  exceedingly  rare  in  car- 
cinoma. Retraction  of  the  nipple,  which  occurs  in  carcinoma  situated 
directly  below  the  nipple,  does  not  occur  in  inflammation.  There  is 
slight  probability  of  inflammation  being  followed  by  involvement  of  the 
axillary  lymphatic  glands,  but  such  involvement  is  common  in  cai'cinoma. 
Chronic  mastitis  is  also  differentiated  from  carcinoma  by  the  fact  that  it 
improves  under  treatment.  Non-malignant  tumors  of  the  breast  are 
diagnosticated  from  chronic  mastitis  by  being  more  defined  in  outline. 

Treatment. — The  treatment  of  chronic  mastitis  is  carried  out  by  hot- 
water  applications  made  by  means  of  a  conical  sponge  laid  upon  the 
breast  two  or  three  times  a  day  ;  by  anointing  the  skin  with  oleate  of 
mercury  ointment  (about  10  per  cent. );  or  by  using  some  form  of  counter- 
irritation  such  as  is  obtained  by  painting  the  parts  with  tincture  of  iodine, 
or  by  the  application  of  a  blister.  Pressure  should  be  made  upon  the 
diseased  gland  by  covering  it  with  cotton  wadding  and  carrying  a  bandage 
of  elastic  webbing  around  the  chest  so  as  to  support  and  press  the  gland 
against  the  ril)s.  The  turns  of  the  bandage  should  be  started  below  the 
breast  and  carried  upward.  Friction,  or  ])ressure  by  corsets  or  other 
.articles  of  clothing,  should  be  prevented.  The  arm  should  be  kept  quiet 
as  much  as  possible,  or  carried  in  a  sling.  The  support  of  the  breast, 
associated  with  equable  pressure,  is  probably  the  most  important  part  of  the 
treatment.  Potassium  iodide  may  be  given  internally  as  an  absorbifacient. 
This  line  of  treatment  should  be  continued  for  months,  since  improve- 
ment is  usually  slow. 

Abscesses  of  the  Breast. 

Pathology. — Suppuration  may  occur  between  the  breast  and  the  skin, 
within  the  gland  itself,  or  between  the  gland  and  the  pectoral  muscle. 
The  first  condition  is  called  supra-mammary  abscess ;  the  second  mam- 
mary abscess;  the  third,  sub-mammary  abscess.  It  is  possible  also  to 
have  tubercular  disease  of  the  breast  causing  the  so-called  "  cold  abscess." 
Acute  abscess  of  the  breast  is  due  here,  as  in  all  other  places,  to  the  en- 
trance of  pyogenic  bacteria,  which  gain  admission,  probably,  through  the 
ducts  of  the  nipple,  or  through  fissures  of  the  nipple  or  integument. 


paget's  disease   of  the  breast.  765 

Supra-mammary  abscess  presents  no  special  symptoms  needing  descrip- 
tion. 

Abscesses  behind  the  breast  push  the  breast  forward,  giving  it  a  very 
conical  appearance.  The  pus  may,  after  a  period  of  protracted  suffering, 
burrow  beneath  the  breast  and  finally  cause  a  spontaneous  opening  at  the 
circumference  of  the  gland,  or  even  near  the  axilla.  Occasionally,  evacua- 
tion occurs  through  the  substance  of  the  gland. 

Mammary  abscess  may  occur  at  several  points  and  riddle  the  breast 
with  pus  pockets  and  sinuses.  If  operative  evacuation  is  to  be  done,  it 
should  be  undertaken  at  an  early  period. 

Suppurative  mastitis  is  an  affection  causing  great  pain  and  exhaustion, 
and  is  usually  found  during  lactation.  Abscesses  in  connection  with  the 
mammary  glands  may  also  be  the  result  of  necrosis  of  the  underlying 
rib,  or  may  be  due  to  spontaneous  opening  through  the  chest  wall  of  a 
pulmonary  abscess  or  suppurative  pleurisy. 

Treatment. — The  measures  to  be  employed  in  acute,  non-suppurative 
mastitis  have  been  discussed  under  the  treatment  of  that  affection.  When 
pus  has  evidently  formed,  it  should  be  evacuated  by  one  or  more  free 
incisions ;  after  which  the  pus  cavity  should  be  well  scraped  out  with  a 
curette.  The  incision  should  be  made  in  the  areola  alone,  or  entirely 
outside  of  it,  because  an  incision  extending  from  the  areola  into  the 
encircling  skin  beyond  is  apt  to  be  followed  by  unsightly  pigmentation  at 
the  circumference  of  the  areola.  Ashhurst  prefers  to  make  the  incision, 
when  possible,  in  the  upper  part  of  the  breast ;  because  the  compression 
bandage,  subsequently  applied,  can  then  better  bring  the  walls  of  the 
abscess  into  apposition,  since  firm  pressure  is  best  obtained  by  band- 
aging from  below  upward.  A  drainage-tube  should  be  placed  in  the 
wound  and  the  incisions  sutured.  This  operation  should  be  done  under 
ether  and  with  the  strictest  antiseptic  precautions.  This  method  of  treat- 
ment is  identical  with  that  for  treating  abscesses  in  any  other  region. 
It  is,  indeed,  possible  that  very  many  abscesses  of  the  breast  could  be 
entirely  prevented  if  firm  support  w^ere  given  to  all  breasts  after  parturi- 
tion, and  if  care  were  taken  that  no  pyogenic  germs  gained  access  to  the 
fissures  upon  the  nipple  or  to  the  milk  ducts.  Thorough  cleansing  after 
each  nursing,  and  bathing  the  breast  at  such  times  with  some  non- 
poisonous,  antiseptic  lotion  would  probably  efficiently  meet  the  latter 
requirement.  After  spontaneous  opening  of  a  mammary  abscess,  the 
sinuses  remaining  must  be  laid  open  and  scraped  out  under  antiseptic  pre- 
cautions. Moderately  firm  compression  with  bandages  cut  to  fit  the  chest, 
or  composed  of  elastic  webbing,  and  applied  over  an  ordinary  gauze 
dressing,  is  an  efficient  adjuvant.  It  is  astonishing  to  see  how  a  breast 
freely  incised  becomes,  under  such  conditions,  an  eflScient  organ  for  nurs- 
ing after  subsequent  pregnancies. 

Paget's  Disease  of  the  Breast. 

This  affection  is  a  peculiar  granular  inflammation  of  the  nipple  and 
the  areola,  which  is  apt  to  be  followed  by  malignant  disease.  If  the 
condition  is  recognized,  the  diseased  structures  should  be  excised  to  pre- 
vent the  occurrence  of  any  further  malignant  involvement. 


'66  DISEASES    OF    THE     MAMMARY    GLANDS. 


Tumors  of  the  Breast. 

Pathology  axd  Symptoms. — Tumors  of  the  male  breast  are  rare. 
The  female  breast  is  the  seat  of  all  forms  of  tumor,  some  of  which  are 
more  common  thau  others.  Carcinomas,  sarcomas,  and  adenomas  are  the 
most  common  growths  found  in  the  breast.  In  not  a  few  cases  the  tumor 
is  a  mixed  one,  but  these  mixed  tumors  usually  contain  adenoid  tissue  as 
one  of  the  elements,  and  are,  therefore,  adeno-fibrtmias,  adeno-cvstomas, 
and  adeno-sarcomas.  It  is  said  that  about  three-fourths  of  the  tumors 
found  in  the  breast  are  carcinomas.  The  commonest  benign  growth  in 
this  situation  is  an  adeuo-tibroma,  which  is  usually  called  a  fibroma  or 
an  adenoma.  It  is.  as  a  rule,  however,  a  mixed  tumor,  and  not  a  pure 
fibroma  or  a  pure  adenoma. 

These  adeno-fibromas  are  very  slow  in  their  growth  and  occur  in  young 
women.  They  are  movable,  hard,  and  encapsulated,  and  are  easily  enu- 
cleated when  removal  is  attempted.  The  growth  is  well  defined  in  outline, 
which  is  quite  difl'erent  from  chronic  lobular  inflammation,  with  which  it 
might  be  confounded.  It  produces  no  pulling  in  of  the  skin,  and  no 
involvement  of  the  lymphatic  glands.  It  is  painless,  except  in  persons 
of  a  nervous  temperament,  when  neuralgic  pain  is  often  present.  A 
tensely  filled  mammary  cyst  may  very  much  resemble  an  adeno-fibroma. 
The  diagnosis  is  accurately  determined  by  puncturing  the  obscure  tumor 
with  a  hypodermic  needle,  through  which  fluid  will  escape  if  it  is  a  cyst 
or  an  adeno-cystoraa. 

The  adeno-cystomas  are  formed  by  occlusion  and  dilatation  of  the 
irregularly  developed  acini  and  ducts,  which  occurs  in  the  adenomatous 
structure.  They  may  consist  of  one  or  more  large  cysts,  containing  often 
a  great  many  smaller  cysts  growing  inward  from  the  outer  wall  of  the 
original  tumor.  The  solidity  of  the  mass  de])euds  upon  the  relative 
quantity  of  the  brownish  fluid  and  the  cyst  wall.  These  tumors  do  not 
infiltrate  the  surrounding  tissues,  they  are  encapsulated  and  do  not  cause 
lymphatic  involvement  :  they  may,  however,  develop  fungous  masses,  the 
surface  of  which  may  bleed.  Such  tumors  present  to  the  naked  eye  the 
appearance  of  malignant  disease  ;  but  such  is  not  their  character.  After 
removal  they  show  no  tendency  to  return. 

Mammary  .sarcomas  vary  very  much  in  their  degree  of  malignancy,  and 
are  at  times  combined  with  adenoid  structures.  The  round-cell  sarcomas, 
with  little  intercellular  substance,  are  probably  the  most  malignant  of  all 
tumors  occurring  in  the  breast.  .Sarcomas  are  found,  as  a  rule,  in  early 
life ;  from  twenty  to  thirty-five  years  being  the  average  age  at  which 
this  disease  is  found.  .Such  tumors  have  a  smooth  surface,  are  elastic, 
mobile,  isolated,  and  rapid  in  growth,  and  the  cutaneous  vessels  are  often 
enlarged.  The  skin  finally  gives  away,  and  a  fungous  protrusion  occurs  ; 
but  the  lymphatic  glands  are  not  involved  until  the  disease  has  made 
great  progress.  Recurrence  after  removal  is  very  apt  to  take  place  about 
the  line  of  incision.  Secondary  growths  in  other  parts  of  the  body  are 
very  usual  in  the  late  stages  of  the  disease. 

Carcinomas  are  frequently  found  in  this  region,  and  are  believed 
sometimes  to  follow  prfilonged  irritation,  such  as  Paget 's  disease  of  the 
nipple,  or  chronic  lobular  inflammation  of  the  gland.  Traumatism  has 
been  assigned  as  a  cause  of  carcinomatous  disease,  and  from  thirty-five  to 
fifty  years  is  the  period  of  life  in  which  its  occurrence  is  most  frequent. 
Scirrhus  or  hard  carcinoma  is  a  verv  hard  tumor  without  definite  outline. 


TUMORS    OF    THE    BREAST.-  767 

It  is  at  first  movable,  but  it  soon  becomes  adherent  to  the  skin  and  to  the 
pectoral  muscle ;  and  the  gland  is  thereby  finally  fastened  to  the  chest 
wall.  The  skin  over  the  growth  is  pulled  in,  and  on  account  of  this  re- 
tracting influence  exerted  upon  the  hair  follicles,  a  characteristic  dimpled 
appearance,  often  called  '"'  pig  skin,"  is  produced.  If  the  tumor  is  directly 
below  the  nipple,  the  nipple  is  slowly  pulled  in  by  the  retraction  until  its 
appearance  is  somewhat  like  that  of  the  navel.  This  retraction  of  the 
nipple  occurs  only  when  the  tumor  is  situated  directly  beneath  the  nipple  : 
hence  its  absence  does  not  indicate  that  the  mammary  growth  is  not  a  car- 
cinoma, unle-ss  the  tumor  is  subjacent  to  the  nipple.  In  some  cases  of 
mammary  carcinomas  there  is  a  slight  discharge  of  fluid  from  the  nipple. 

The  absence  of  pain  or  tenderness  in  the  early  stages  of  the  disease 
often  misleads  the  patient  as  to  its  dangerous  character,  and  this  error  is 
enforced  by  the  comparatively  slow  increase  in  size  of  the  lump  found  in 
the  breast.  In  the  later  stages  of  the  disease,  the  pain  may  become  great, 
and  seriously  so  when  the  axillary  glands  become  the  seat  of  secondary 
infiltration  and  produce  pressure  upon  the  nerve-trunks  in  the  arm-pit. 
Instead  of  scirrhous  carcinomas  being  nodular,  they  may  at  times  occur 
as  a  rapid  infiltration  of  the  breast. 

Gradually  the  skin  overlying  the  tumor  becomes  ulcerated,  and  from 
the  surface  of  this  foul  sore  escapes  a  thin,  and  often  bloody,  discharge. 
Severe  hemorrhage  may  supervene  from  such  an  ulcer,  but  is  readily 
stopped,  as  a  rule,  by  slight  pressure.  The  carcinomatous  ulceration  may 
slowly  spread  over  the  whole  front  of  the  chest.  The  lymphatic  glands  of 
the  axilla  are  usually  quite  early  involved,  though  the  enlargement  may 
not  be  perceptible  through  the  skin  until  they  have  attained  quite  a  large 
size. 

The  cervical  glands  are  not  involved  until  some  time  after  the  axillary 
glands  have  become  the  seat  of  carcinomatous  infiltration.  Pain  and 
swelling  of  the  arm  from  pressure  upon  the  nerves,  veins,  and  lymphatics, 
is  one  of  the  late  symptoms.  Secondary  growths  occur  in  the  liver,  lungs, 
and  bones,  and  finally  death  supervenes. 

In  cases  where  there  is  great  increase  in  the  fibrous  tissue  of  the  tumor, 
the  pathological  condition  is  called  atrophic  scirrhus.  This  form  of  the 
disease  may  exist  with  very  little,  or  no  progress,  for  months  or  years. 
This  quiescent  form  of  carcinoma  is  simply  one  of  very  slow  growth,  and 
its  final  result  difters  in  no  way  from  that  of  other  cases. 

Hard  carcinoma  is  a  disease  most  common  in  women  about  forty  to  fifty 
vears  of  asre.  Soft  carcinoma,  or  encephaloid,  occurs  at  an  earlier  period 
bf  life. 

Soft  carcinomas  are  much  more  rapid  in  their  growth,  and  much  more 
malignant,  than  hard  carcinomas ;  and  appear  as  round  movable  tumors, 
situa'ted  deeper  in  the  breast  than  scirrhus.  On  examination,  such  growths 
feel  knobby,  but  are  not  exceedingly  hard  ;  they  are  elastic,  and  at  some 
places  feel  almost  as  fluctuating  as  cystic  tumors.  The  integument  overlying 
them  becomes  red  and  cedematous,  and  suggests  the  occurrence  of  suppu- 
ration. Ulceration  soon  supervenes  and  portions  of  the  tissue  become 
detached,  though  there  is  not  the  same  tendency  to  fungous  protrusion  as 
is  found  in  some  other  tumors.  The  disease  is  accompanied  with  com- 
paratively little  pain,  but  the  lymphatic  glands  and  viscera  are  affected 
quite  eariv.  In  the  space  of  eight  or  ten  weeks  these  growths  may  assume 
the  size  of  a  cocoanut. 

The  clinical  diflference  between  hard  and  soft  carcinoma  resides  in  the 
comparative  hardness  and  the  chronicity  of  progress  of  the  former.     The 


768  DISEASES    OF    THE    MAMMARY    GLANDS. 

round-cell  sarcoma  resembles,  clinically,  the  soft  carcinoma,  but  is  circum- 
scribed and  encapsulated,  while  the  latter  is  an  iuHltrated  growth.  The 
average  duration  of  soft  sarcoma  is  from  six  to  twelve  months,  while  that 
of  a  hard  carcinoma  is  about  two  and  a  half  years. 

Cystic  or  colloid  degenerations  may  occur  in  both  forms  of  carcinomas, 
and  occasionally  small  ab.scesses  may  develop  in  connection  with  them. 

Cystic  tumors  of  the  breast  are  not  infrequently  found.  They  may 
occur  during  lactation,  and  then  often  contain  milk.  Glandular  cysts  of 
various  kinds  occur  in  the  organ,  and  contain  fluid  varying  in  color  from 
a  light  straw  to  a  red.  These  benign  tumors  are  smooth  in  outline,  and 
do  not  involve  the  lymphatic  glands,  or  ulcerate.  These  are  sometimes  so 
hard  as  to  give  the  surgeon's  fingers  the  impression  of  a  solid  growth.  At 
other  times  they  may  be  distinctly  fluctuating.  It  is  at  times  good  policy 
to  puncture  the  tumor  before  attempting  to  remove  it  by  the  knife,  for  I 
have  seen  simple  cysts  excised  under  the  impression  that  they  were  carci- 
nomatous nodules.  The  surgeon  must  carefully  distinguish  a  benign  cyst 
from  a  malignant  tumor  which  has  undergone  cystic  degeneration. 

Treatment. — Simple  cysts  are  treated  by  evacuation  of  the  fluid  with 
an  aspirator,  and  then  setting  up  an  irritation  by  scraping  the  interior  of 
the  wall  with  the  point  of  a  needle,  or  by  introducing  some  counter-irri- 
tant, such  as  the  tincture  of  iodine,  or  a  5  per  cent,  solution  of  carbolic 
acid.  If  this  does  not  produce  obliteration  of  the  cyst,  it  may  be  incised 
and  packed  w'ith  antiseptic  gauze  in  order  to  make  it  granulate  from  the 
bottom.  If  the  tumor  is  a  large  one,  or  if  there  are  various  cysts,  prompt 
cure  will  be  better  obtained  by  enucleating  the  cyst  from  the  breast  tissue 
by  means  of  an  ordinary  straight  or  elliptical  incision  through  the  skin. 
The  breast  itself  should  not  be  removed  unless  its  structure  is  practically 
riddled  with  hard  cysts.  Excision  of  the  breast  is  then  justifiable  be- 
cause a  return  of  the  enlargement  would  seem  to  indicate  a  malignant 
tumor,  and  would,  therefore,  give  great  anxiety  to  the  patient. 

Clinically,  it  is  frequently  impossible  to  diagnose  with  certainty  sarcoma 
from  carcinoma,  or  either  of  these  from  mixed  adenoid  growths.  It  is 
the  surgeon's  duty  to  be  guided  in  treatment  more  by  the  clinical  symp- 
toms than  by  the  supposed  microscopical  or  histological  structure  of  the 
tumor. 

The  hard,  lobulated,  slow  growth,  which  does  not  draw  in  the  skin,  is 
probably  innocent.  An  elastic,  rapid  growth  is  almost  certainly  malig- 
nant. JExperieuce  has  taught  me  that  any  growths  in  the  breast,  which 
do  not,  after  a  few  weeks'  treatment,  show  evidence  of  diminishing  in 
size,  had  better  be  removed  by  operation.  If  the  tumor  is  a  small  one,  a 
single  incision  will  enable  the  operator  to  enucleate  it  from  the  gland 
tissue  without  mutilation  of  the  organ.  If  it  is  innocent,  the  patient's 
mind  will  be  relieved,  and  the  slight  operation  will  be  fully  justified  by 
the  mental  relief  given  to  the  patient.  If  these  small  growths  thus  early 
removed  prove  to  be  malignant,  both  the  surgeon  and  the  patient  are  put 
upon  their  guard,  and  warned  of  the  absolute  necessity  for  instant  re- 
moval of  the  entire  breast  and  all  the  axillary  glands  upon  the  first  signs 
of  recurrence. 

Sarcomas  may  be  as  malignant,  or  more  malignant,  than  carcinomas. 
It  is  of  little  interest  to  the  patient  to  know  from  which  she  suffers,  hence 
these  two  forms  of  tumor  must  be  treated  alike.  Pure  fibromas  are  not 
apt  to  recur,  if  all  the  tumor  structure  is  removed  ;  but  this  form  of  tumor 
is  rare.  The  removal  of  adeno-fibromas  and  adeno-cystomas  may  be 
advisable,  since  the  difficulty  in  diagnosing  them,  before  microscopical 


EXCISION    OF    THE    BREAST.  769 

examination  is  made,  is  great.  Pregnancy  hastens  the  development  of 
tumors  in  the  breast ;  undoubtedly  because  of  the  increased  blood-supply 
to  the  organ. 

Excision  of  the  Breast. 

When  there  is  the  slightest  reason  to  believe  that  the  tumor  is  a  malig- 
nant one,  it  is  proper  to  perform  excision  of  the  mammary  gland.  It  is 
only  in  benign  growths,  or  in  those  which  are  expected  to  prove  them- 
selves benign  when  subsequent  histological  study  is  made,  that  partial 
removal  of  the  gland  is  justifiable.  The  accepted  belief  that  malignant 
growths  are  originally  local  and  not  the  result  of  constitutional  change  is 
a  strong  argument  in  favor  of  early  and  radical  operation.  Operation 
should  not  be  pei'formed  when  the  disease  has  become  so  extensive  that  it 
is  evidently  impossible  to  remove  all  the  tissue  visibly  infiltrated ;  nor  in 
patients  who  presumably  cannot  stand  the  shock  of  the  operation.  Under 
our  present  methods  of  operation,  however,  excision  of  the  breast  is 
almost  devoid  of  danger.  I  feel,  therefore,  that  it  is  justifiable  to  attack 
these  growths  under  nearly  all  circumstances,  and  to  follow  the  first 
operation  by  other  operations  when  recurrence  takes  place,  until  it  is 
manifestly  impossible  for  the  knife  to  get  beyond  the  limits  of  infiltration 
as  discernible  by  the  naked  eye.  It  is  the  tendency  to  postponement  on 
the  part  of  the  patient,  and  the  encouragement  which  such  delay  receives 
at  the  hands  of  some  physicians,  that  prevent  the  best  surgical  aid  being 
given  until  the  whole  gland  is  involved  in  the  disease.  Patients  in  whom 
it  is  evident  that  the  cervical  glands  are  involved,  as  well  as  the  axillary, 
and  in  whom  secondary  visceral  lesions  have  occurred,  az'e  not  proper 
subjects  for  operation. 

In  proceeding  to  attack  the  growth,  the  surgeon  must  recollect  that 
any  small  portion  of  the  infiltrated  tissue  left  behind  is  a  source  of  immi- 
nent risk,  and  his  incision  must,  therefore,  be  made  so  far  beyond  the 
limit  of  the  growth  as  to  avoid,  as  far  as  possible,  such  contingency.  It 
is  an  imperative  rule  that  the  axilla  be  opened  freely  and  all  the  lymph- 
atic glands  of  that  region  enucleated  in  every  case  of  malignant  tumor 
of  the  breast  subjected  to  operation.  I  have  often  found  the  glands  high 
up  in  the  axilla,  and  those  surrounding  the  axillary  vessels  involved 
in  the  disease,  when  no  evidence  of  such  glandular  implication  was  de- 
tected through  the  skin.  I  am,  therefore,  never  satisfied  until  I  have 
laid  bare  the  axillary  vein,  and  carried  my  finger  as  far  up  as  the  clavicle 
in  the  effort  at  finding  these  glandular  foci  of  malignant  disease. 

The  operation  of  excision  of  the  breast  is  performed  by  carrying  a 
circular  or  elliptical  incision  around  the  gland,  about  three-quarters  of 
an  inch  from  the  circumference  of  the  breast,  making,  what  has  been 
called  by  Gross,  a  dinner-plate  incision.  After  this  extensive  incision, 
the  whole  gland  is  dissected  from  the  fascia  covering  the  pectoral  muscle, 
and  I  prefer  always  to  remove  this  fascia  as  well  as  the  breast. 

If  there  is  evidence  of  infiltration  of  the  underlying  muscle,  the  greater 
and  lesser  pectorals  should  be  removed,  since  the  stiffness  of  the  arm  left 
after  such  mutilation  is  preferable  to  early  return  of  the  disease. 

An  incision  from  an  inch  and  a  half  to  two  inches  long  is  then  carried 
up  into  the  axilla  a  little  below  the  edge  of  the  greater  pectoral  muscle. 
All  the  lymphatic  glands,  and  a  large  portion  of  the  fatty  tissue,  are  then 
scraped  out  of  the  axilla  by  means  of  the  finger  and  by  the  very  careful 
use  of  the  scalpel  and  forceps.     The  majority  of  the  glands  lie  close  to 

49 


770  TUMORS    OF    THE     BRKAST, 

the  ribs,  and  should  be  looked  for  in  that  situation,  thouyh  every  portion 
of  the  axillary  space  and  that  beneath  the  cdavicle  should  be  thoroughly 
searched  for  small  glands.  It  is  wise  to  clear  away  the  tissue  around 
the  axillary  vein  freely  first,  in  order  that  its  location  may  be  clearly 
appreciated.  Laceration  of  the  vein  gives  rise  to  copious  hemorrhage. 
It  is  easily  arrested,  however,  by  lateral  ligature,  by  suturing  the 
opening  in  the  vessel  with  tine  catgut,  or  by  gra.sping  the  margin  of 
the  tear  with  hemostatic  forceps,  which  should  be  allowed  to  remain  in 
the  wound  for  forty-eight  hours.  The  skin  covering  the  posterior  por- 
tion of  the  axilla  should  be  perforated  for  the  admission  of  a  rubber 
drainage-tube,  which  will  permit  the  exit  of  wound  fluids  while  the 
patient  lies  upon  her  back.  The  axillary  wound  is  then  closed  by 
sutures,  and  the  raw  surface  left  by  the  removal  of  the  breast  somewhat 
contracted  by  strong  sutures  carried  across  it.  A  considerable  degree  of 
approximation  can  be  obtained  if  the  skin  and  subcutaneous  tissue  are 
separated  from  the  chest  wall  by  dissecting  up  the  edges  a  short  distance. 
It  is  well  to  place  over  the  open  surface  a  piece  of  perforated  rubber 
tissue,  or  Lister  protective,  before  applying  the  gauze  dressing,  because 
the  gauze  placed  directly  over  the  raw  surface  becomes  adherent  from  the 
drying  of  the  secretions,  and  gives  pain  when  the  dressing  is  removed. 
Skin  grafts  or  skin  shavings  can  be  applied  to  hasten  healing  after  granu- 
lation has  been  established — say  at  the  end  of  ten  days.  Grafts  of  frog 
skin  have  been  applied  by  me  for  this  purpose,  but  without  much  success. 
The  first  dressing  should  be  changed  at  the  end  of  twenty-four  hours, 
since  there  is  much  oozing  from  this  large,  open  wound.  Subsequent 
dressings  are  made  when  pain,  fever,  odor,  or  soiling  by  the  secretions 
indicate  their  necessity. 


INDEX. 


ABDOMEN,  aspiration  of,  57<i 
exploratory  incision  of,  571 
method  of  operating  upon,  572 
section  of,  572 
tapping  of,  576 
wounds  of,  571 

Senn's  hydrogen  test  for,  571 
Abdominal  absces?,  577 

cavity,  drainage  of,  573 

irrigation  or  washing  out  of,  573 
drain-tube,  573 

operations,   method  of  performing, 
572 

after-treatment,  574 

purgatives  after,  576 
section,  672 
surgery,  572 
Abscess,  39 

abdominal,  577 
acute,  52 
alveolar,  657 
atheromatous,  262 
cerebral,  186 
chronic,  53 
cold,  53 

in  caries,  313 
contents  of,  52 
definition  of,  51 
diagnosis  of,  53 
diffused,  61 
drainage  of,  54 
embolic,  66 
fluctuation  in,  53 
hyper-distention  of,  54 
in  amputation  stumps,  749 
in  bones,  eradication  of,  316 
incision  of,  54 
injection  of,  54 
in  spinal  tuberculosis,  453 
intermeningeal,  186 
ischio-rectal,  642 
metastatic,  53,  65 
of  antrum,  533 
of  bone,  arthritis  from,  317 
of  chest,  543 
of  frontal  sinuses,  634 
of  joints,  449 
of  kidney,  658 

tubercular,  660 
of  liver,  603 

of  mammary  glands,  764 
of  mediastinum,  547 
of  pancreas,  607 


Abscess  of  rectum,  642 

of  teeth,  557 

of  thyroid  gland,  551 

of  tongue,  569 

of  tonsils,  562 

of  vulva,  724 

opening  of,  54 

parietal,  578 

pelvic,  577 

perineal.      {See  Abscess,  ischio-rec- 
tal.) 

perinephritio,  659 

peri-rectal,  642 

phlegmonous,  53 

pointing  of,  53 

psoas,  453 

pulmonary,  547 

putrefaction  in,  62 

residual,  52 

retro-pharyngeal,  563 

spontaneous  opening  of,  52 

subcranial,  186 

treatment  of,  54 

tubercular,  58 
of  bones,  317 

varieties  of,  62 
Absorbents.     [See  Lymphatics.) 
Absorption  of  spine.     {See  Spondylitis.) 
Acetabulum,  fracture  of,  379 

perforation  of,  in  hip  disease,  463 
Achilles,  tendon  of.  {See  Tendo  Achillis.) 
Acromion,  fracture  of,  386 
Actinomycosis,  559 
Actual  cautery,  143 
Acupressure,  methods  of  applying,  236 

of  arteries,  235 

of  varicose  veins,  247 
Acupuncture,  143 

in  neuralgia,  208 
Adams's  osteotomy  saw,  517 
Adenitis,  250 

Adenocele.     {See  Adenitis.) 
Adenoid  tumor.     {See  Adenoma.) 
Adenoma,  101 

of  pharynx,  531 
Adhesions  of  vulvar  lips,  723 
Air-bed,  in  fractures,  337 
Air  in  veins,  241 
Air-passages,  diseases  of.  534 

foreign  bodies  in,  534 
Alse  nasi,  restoration  of,  533 
Albuminous  degeneration.     {See  Myx- 
cedema.) 


^  rz 


INDEX. 


Allis's  test  for  femoral  fracture,  421 

for  hip  dii-loctttions,  507 
Alopeciii  in  svjiliilis,  77 
Alteratives  in  inflatmnation,  4'' 
Alveolus,  abscess  of,  567 
Amputation,  743 

after-treatment,  748 
antipyretic.     [See  Amputation,  pri- 
mary.) 
bleeding  from  bone-end  in,  747 
by  lateral  flaps,  747 
carpo-metacarpal,  752 
Chopart's,  760 
circular  method,  74(5 

modified,  746 
chronic,  744 

contra-indications  for,  743 
definition,  743 
drainaeje  in,  747 
flaps,  740 
for  ankylosis,  472 
for  bone  tumors,  320 
for  elephantiasis,  161 
for  gangrene,  63 
for  phalangeal  fractures,  415 
Hey's,  761 
in  caries,  317 
indications  fi.r,  743 
in  secondary  hemorrhage,  23!t 
instruments  required  for,  744 
inter-carpal,  752 

intrapyretic.    (SV'  Amputation,  sec- 
ondary.) 
Lisfranc's,  761 
location  of,  744 
metacarpo-phalangeal,  753 
nietapyretic.     {See  Amputation,  in- 
termediate.) 
metatarso-phalangeal,  701 
necrosis  of  bones  after,  309 
Pirogoff's,  750 
points  of  election  in,  744 
primary,  744 
of  arm,  752 

of  breast.      {See  Excision  of  mam- 
mary glands  ) 
of  forearm,  752 
of  hand,  753 
of  leg,  757 

of  penis.     {See  Penis,  excision  of.) 
of  phalanges,  of  foot,  761 

of  hand, 754 
of  thigh,  757 
of  thumb,  763 
saw,  745 
secondary,  744 
site  of,  744 
stumps,  abscesses  in,  749 

aneurism  in,  749 

chorea  of,  749 

conical,  749 

disea-es  of,  749 

drainage  and  dressing  of,  747 

epithelioma  of,  749 

fracture  in,  749 


Amputation  stumps,  injuries  of,  749 

necrosis  in,  749 

osteomyelitis  in,  749 

redressing  of,  749 

spasm  in,  749 

ulceration  of,  749 

varix  of,  749 
Syme's,  757 
tarsu-metatarsal,  761 
Tcule's  method,  748 
tertiary,  744 
through  ankle-joint,  757 

elbow-joint,  752 

liip-joint,  754 

knee-joint,  757 

niedio-tarsal  joint,  760 

metatarsus,  761 

shoulder-joint,  750 

wrist-joint,  752 
time  for,  744 
transfixion  in,  747 
varieties  of,  743 
Amussat's  method  of  oolotomy,  .597 
Anaesthesia,  128 

accidents  during,  128 
chloroform,  129 
cocaine,  129 
ether,  1.30 
in  aneurism,  267 
local,  128 
nitrous  oxide,  129 
Anal  fissure,  642 

fistule,  643 
Anastomosis,  intestinal,  602 

after  resection  of  intestine,  603 
Anel's  method  of  ligation,  280 
Anemia,  acute,  bandaging  of  limbs  in 
227 

compression  of  aorta  in,  227 

from  hemorrhage,  227 

transfusion  in,  228 
Aneurism,  563 

anaesthesia  in,  267 

aphonia  in, 267 

bruit  in,  269 

causes  of,  265 

cirsoid.     {See  Arterial  varix.) 

course  of,  271 

diagnosis  of,  269 

dissecting,  264 

fusiform,  264 

laminated  fibrin  in,  267 

murmur  in,  269 

neuralgia  in,  267 

pain  in,  267 

paralysis  in,  267 

pathology  of,  266 

pulsation  of,  267 

pulse  in,  268 

racemose.     {See  Arterial  varix.], 

recurrent  pulsation  in,  283 

sacciform,  264 

special.     {See  Individual  arteries.) 

symptoms  of,  267 

terminations  of,  271 


INDEX. 


773 


Aneurism,  thrill  of,  268 
traumatic,  255 
treatment  of,  272 

by  arterial  compression,  273 
by  direct  compression,  273 
by  excision  of  sac,  273 
by  flexion  of  joints,  277 
by  ligation  of  arteries,  279 
by  tourniquets,  276 
centra-indications    for    ligation 

in,  282 
indications  for  ligation  in,  282 
varicose,  256 

veins  in.  267 
varieties  of,  263 
venous  occlusion  in,  267 
Aneurismal  varix,  256 
Aneurismoid  varix,  257 
Angeioleucitis,  248 
Angeioma,  96 

cavernous,  96 
treatment  of,  97 
Angular  curvature  of  spine,  453 
extension  in  dislocations,  485 
in  hip  disease,  464 
Animals,  rabid,  bites  of.     [See  Hydro- 
phobia; poisoned  wounds.) 
Ankle-joint,  amputation  through,  757 
dislocations  of,  512 
excision  of,  525 
Ankles,  weak,  733 
Ankylosis,  470 

continuous  extension  in,  472 
excision  in,  516 
from  burns,  162 
in  arthritis,  449 
of  elbow,  after  fractures,  399 
of  spine,  455 
passive  motion  in,  472 
rupturing  of  adhesions  in,  472 
Anodynes  in  inflammation,  47 
Anterior  tibial  artery.     [See  Artery.) 
Antero-posterior  curvature  of  spine,  4-54 
Antipyretic  amputation.     [See  Amputa- 
tion, primary.) 
Antrum,  abscess  of,  533 
Antisepsis,  134 

Antiseptics  in  inflammation,  47 
Anus,  artificial,  592 

repair  of,  593 
eczema  of,  633 
fissure  of,  642 
imperforate,  682 
malformations  of,  632 
painful  ulcer  of.     [See  Anus,  fissure 

of) 
prolapse  of.     [See  Kectum,  prolapse 

of.) 
pruritus  of.  633 
tumors  of,  652 
ulceration  of,  648 
Aphasia  in  brain  injury,  190 
Aphonia,  from  foreii;n  bodies  in  oesoph- 
agus, 565 
in  aneurism,  267 


Apostoli's  treatment  of  uterine  tumors, 

608 
Apparatus,  aspiration,  515 
extension,  342 
for  spinal  curvatures,  733 
to  prevent  semilunar  dislocations,  514 
Appendicitis,  594 
Appendix  vermiformis,  inflammation  of, 

594 
Arm,  amputation  of,  752 
Arterial  hematoma,  252 

varix,  300 
Arteries,  atheroma  of,  262 
acupressure  of,  235 
calcareous,  ligation  of,  262 
calcification  of,  262 
collateral  circulation  in,  282 
degenerative  changes  in,  260,  262 
inflammation  of,  259 
ligation  of,  232 

for  Elephantiasis,  161 
in  continuity,  285 
in  lingual  cancer,  -560 
in  secondary  hemorrhage,  238 
special.     [See  Individual  arte- 
'  ries.) 

ossification  of,  263 
torsion  of,  234 
varicose,  300 
wounds  of,  222,  252 
Arteriotomy,  144.     [See  also  Bleeding.) 
Arterio-venous  fistules,  266 
sacculated,  258 
•    wounds,  256 
Arteritis,  259 

idiopathic,  261 
rheumatic,  261 
syphilitic,  261 
traumatic,  260 
Artery,  anterior  tibial,  ligation  of,  295 
axillary,  ligation  of,  290 
brachial,  ligation  of,  289 
brachio-cephalic.   [See  Artery,  inno- 
minate.) 
common  carotid,  ligation  of,  298 

iliac,  ligation  of,  297 
external  carotid,  ligation  of,  294 

iliac,  ligation  of,  297 
femoral,  ligation  of,  297 
intercostal,  hemorrhage  from,  543 
rupture  of,  in  rib  fractures,  373 
treatment  of,  373 
internal  carotid,  ligation  of,  294 

iliac,  ligation  of,  200 
posterior  tibial,  ligation  of,  295 
radial,  ligation  of,  289 
subclavian,  ligation  of,  291 
ulnar,  ligation  of,  289 
Arthrectomy".     (See  Joints,  excision  of.) 

in  caries,  817 
Arthritis,  449 

acute  and  chronic,  449 
atrophic,  469 
deformans,  468 
from  bone  abscess,  317 


774 


INDEX 


Arthritis,  gonorrhooal,  450 
of  hip-joint,  461 
abscess  in,  468 
deformity  in,  463 
perforation    of  acetabulum    in, 

463 
posture  in,  463 
treatment  of,  464 
of  sacro-iliac  articulation,  460 
of  vertebral  articulations,  451 
diagnosis  of,  454 
treatment  of,  456 
rheumatoid.     {See  Osteo-arthritis.) 
suppurative,  449 
syphilitic.  467 
tubercular,  450 

of    special    joints.     (See    Indi- 
vidual joints.) 
prognosis  of,  451 
treatment  of,  451 
Arthrotomy.   (.SVe  Joints, exploration  of.) 
Articular  changes  in  dislocations,  478 
in  hysteria,  570 
in  locomotor  ataxia,  46'.l 
in  neuralgia,  470 
Artificial  anus,  592 
menopause,  608 
Asepsis,  133 

Aseptic  wound-fever,  65 
Aspiration,  144 

hypodermic,  144 
ol  abdomen,  576 
of  bladder,  683 
of  hydrocephalus,  183 
of  joints,  515 
of  kidney,  665 
of  liver  abscess,  604 
of  ovarian  cysts,  610 
of  pericardium,  220 
of  pleura,  545 
Aspirator,  144,  515 
Asthenic  fever,  44 
Astragalus,  dislocations  of,  512 
Astringents  in  inflammation,  47 
Asymmetry    of    lower    limbs    in    spinal 

curvatures,  732 
Ataxia,  locomotor,  joint-changes  in,  469 
Atheroma,  260 
Atlo-axoid  dislocations,  488 
Atony  of  bladder,  674 
Atrophy  of  bones,  318 
Auscultation  of  ce>ophagus,  568 
Awl,  Horner's,  254 
Axillary  artery.     {See  Artery.) 

glands,  infiltration  of,  in  mammary 
carcinoma,  767 


BACILLUS  tuberculosis,  71 
Bacteria.  37 
varieties  of,  38 
Balanitis,  720 
Balano-posthitis,  720 
Bandage,  for  hand  and  heel  in  lithotomy, 
687 


Bandage,  Barton's,  368 

Esmarch's,  475 

for  fractured  ribs,  376 

Morton's,  376 
Bandages,  142 

gypsum,  344 

rubber,  142 
Barbadoes  leg.     (See  Elephantiasis.) 
Barker-WiUard  irrigation  curette,  518 
Barton's  bandaje,  368 
Basedow's  disease.     (See  Goitre,  exoph- 
thalmic.) 
Batte}''s  operation.  {See  Oophorectojny.) 
Bed,  air,  in  fractures,  337 

fracture,  3:'.7 

water,  in  fractures,  337 
Bedsores  from  splints,  343 

in  spinal  inflammation,  200 
Bifid  spine,  198 

uvula.     (See  Palate,  cleft.) 
Bigelow's  litholapaxy  apparatus,  687 

lithotrites,  684 
Bistoury,  126 

Bites    of   rabid    animals.      (See    Hydro- 
phobia ) 
Bladder,  aspiration  of,  683 

atonj'  of,  674 

calculi  in,  676 

congenital  defects  of,  668 

displacements  of,  671 

exstrophy  of,  669 

fistulffi  of,  674 

inflammation  of,  671 

neuroses  of,  674 

operations  upi-n,  683 

paralysis  of,  674 

ribbed  and  sacculated.  672 

sounding  of,  678 

tuberculosis  of,  674 

tumors  of,  675 

urinary,  examination  of,  668 

washing  out  of,  673 
Bleeding,  144 

in  treatment  of  hemorrhage,  '2'2f< 
Blenorrhagia.     (See  Urethritis,  specific.) 
Blood,   coagulation   of.    in    hemorrhage, 
'  224:  etseij. 

extravasation  of,  221 

hyperinosis  (pf,  41 
'  inflammatory,  41 

in  inflammation.  41 

-letting.  143 
I  in  inflammation,  47 

I  transfusion  of.  228 

Bloodclot.  healing  by,  313 

organization  of,  225 
Bloodless     method     of    operating,    Es- 
march's.    {See  Bandage,  Esmarch's.) 
Bloodvessels,  in  inflammation,  40 
Bodies,  foreign,  in  nose,  526 
in  tongue,  560 

loose,  in  hydrocele  of  tunica  vagi- 
nalis, 711 
in  joints,  472 
melon-seed,  176 


INDEX. 


775 


Bodies,  rice-like,  176 
Body,  thyroid,  diseases  of,  548 
Boil,  gum,  557 
Boils,^155 
Bond's  splint,  412 
Bone-cutting  pliers,  516 
Bone  drill,  524 
forceps,  51fi 

death  of.     [See  Neciosis.) 
grafting  of,  311 
inflammation  of,  304 
plates,  Senn's  decalcified,  for  anasto- 
mosis, 602 
softening  of,  319 
transplantation  of,  311 
ulceration  of.     [See  Caries.) 
Bones,  atrophy  of,  318 
bending  of,  321 
caries  of,  313 

cold  abscess  in,  313 
drilling  of,  in  abscess,  317 

in  ununited  fracture,  349 
erosion  of.     [See  Caries.) 
exfoliation  of,  309 
hypertrophy  of,  318 
injuries  of,  320 
in  osteomalacia,  321 
mortification  of,  307 
necrosis  of,  307.     {See  also  Xecrosis.) 
of  face,  fracture  of,  365 
resection  of,  in    ununited    fracture, 

349 
sclerosis  of,  304 
tuberculosis  of,  313,  317 
tumors  of,  320 

amputation  for,  320 
central,  320 
endosteal,  320 
periosteal,  320 
ulceration  of,  tuberculous,  313 
■wiring  of,  in  ununited  fracture,  350 
Bony  ankylosis.     {See  Ankyloih.) 
Bougie,  bulbous,  701 
dilating,  703 
exploring,  701 
filiform,  704 
for  female  urethra,  708 
oesophageal,  569 

introduction  of,  569 
rectal,  651 
whalebone,  704 
Boutonniere  operation  on  urethra.     (-See 

External  urethrotomy.) 
Bowel.  {See  Intestines.) 
Bow-legs,  740 

Brachial  artery.     {See  Arter}'.) 
Brachio-cephalic    artery.     (.See    Artery, 

innominate.) 
Brain,  abscess  of,  186 
compression  of,  195 

trephining  for,  197 
concussion  of,  193 
contusion  of,  193 
dropsy  of.     (.See  Hydrocephalus.) 
fungus  of,  192 


Brain,  hernia  of,  192.     {See  also  Fungus 
cerebri.) 
congenital,  182 
inflammation  of,  183 

operative  treatment,  186 
sequelse,  186 
symptoms,  184 
treatment,  185 
injuries  of,  191 

aphasia  in,  190 
Cheyne-Stolies   respiration    in, 

190 
choked  disk  in,  190 
laceration  of  193 
lesions,  localization  of,  186 
trephining  for  lesions  of,  189 
tumors  of,  198 
•wounds  of,  192 
Breast.     (.See  Mammary  glands.) 

diseases  of,  763 
Briddon's  arterial  compressor.  277 
Brisdor's  method  of  ligation,  281 
Broca's  square,  188 
Bronchocele,  549 

exophthalmic,  549 
Bruise.     {See  Contusions.) 
Bruit,  in  aneurism,  268 
Bryant's   fractured    clavicle    apparatus, 
384 
rectangle,  421 
Bubo,  syphilitic,  76 

Bubonocele,  625.   (.See  Hernia,  inguinal.) 
Bulbous  bougie,  701 
Bullets,  extraction  of,  125 
Bunion,  180 
Burns,  161 

constitutional  efi'ects  of,  162 

deformity  from,  162 

duodenal  ulcer  from,  163 

erysipelas  In.  163 

erythematous,  162 

from  chemicals,  161 

from  electricity,  161 

necrotic,  162 

prevention  of  cicatricial  contraction 

in,  164 
treatment  of,  163 
vesicating,  162 
Bursa,  adventitious,  179 

inflammation  of,  178 
Bursitis,  178 
chronic,  179 
treatment  of,  180 
Butcher's  saw,  for  excisions,  518 

excision  pliers,  518 
Button-hole   operation    for    urethrocele, 
698 


pALCTJLI,  crushing  of,  683 
\J     encysted,  679 

in  gall-bladder,  605 

in  urachus,  670 

renal,  661 

urethral,  705 


776 


INDEX. 


Calculi,  vesical,  (i7<5 

causes  of,  67(5 
construction  of,  676 
diafjnosis  of,  678 
number  of,  676 
sounding  for,  678 
symptoms  of,  677 
treatment  of,  67'.' 
solvent,  67'.) 
varieties  of,  677 
Calibre  of  urethra,  method  of  determin- 
ing, 702 
Callous  ulcer,  57.     (See,  also,  Ulcer.) 
Callus,  in  joint  fracture.«,  336 
in  repair  of  fractures,  335 
provisional,  335 
Canal  of  NucU,  hydrocele  in,  71;! 
Cancer,  106.   {See,  also,  Carcinoma;  epi- 
thelioma. ) 
colloid,  108 
hard,  107 
soft,  108 
Canula,  chemise,  in  lithotomy,  690 

tracheal,  539 
Caput  obstipum.   { {See  Torticollis.) 
Carbuncle,  156 

incision  of,  157 
Carcinoma,  105 
colloid,  108 
encephaloid,  108 
of  bladder,  675 
of  mammary  glands,  766 
of  penis,  722 
of  rectum,  652 
scirrhous,  107 
Caries,  45 

amputation  in,  317 
arthrectomy  in,  317 
central,  317" 
drv,  304 
of'bone,  313 
sicca.     {See  Ostitis.) 
Carotid  artery.     {See  Artery.) 
Carpal  bones,  excision  of,  521 

fractures  of,  413 
Carpus,  dislocations  of,  502 
excision  of,  521 
fractures  of,  413 
Cartilage,  epiphvseal,  inflammation   of, 

318 
Cartilages,  dislocations  of,  512 
costal,  512 
ensiform,  513 
epiphyseal,  325 
semilunar,  .523 
fractures  of  costal,  372 
laryngeal,  370 
nasal,  365 
repair  of,  .336 
loose,  in  joints,  472 
Castration,  717 
Catarrh,  nasal,  528 

purulent,  39 
Catgut  ligatures,  137 

rings,  for  intestinal  anastomosis,  602 


Catgut  sutures,  136 
Cathartics  in  inflammation,  48 
Catheter,  double  or  two-way,  673 

silver,  706 
Catheterization,  in  spinal  inflammation, 
202 

of  ureters,  'i68 

of  urethra,  707 
in  female,  708 
Callin,  744 

Cauliflower  growlh>,  100 
Cautery,  143 

in  neuralgia,  208 

in  neuritis,  205 
Cellular  erysipelas,  64 
Cellulitis,  diftuse,  64 
Cerebral  abscess,  186 

fungus,  192 

hemorrhage,  186 

localization,  186 
Cerebritis,  183 
Cerebrospinal  fluid,  escape  of,  in  cranial 

fracture,  359 
Cervical  glands,  infiltration  of,  in  mam- 
mary carcinoma,  767 
Chain  saw,  517 
Chancre,  diagnosis  of,  diflerential,  79 

hard,  75 

infecting,  76 

of  lip,  555 

of  mouth,  559 

of  vagina,  727 

of  vulva,  725 

phagedenic,  76 

syphilitic,  75 
Chancroid,    diagnosis    of,    differential, 
79 

of  penis,  721 

of  vagina,  727 

of  vulva,  725 
Charbon, 122 
Charcot's  disease,  469 
Chemicals,  burns  from,  161 
Chest,  abscesses  of,  542 

contusions  of,  542 

diseases  of,  542 

sinus  of,  .547 

wounds  of,  543 
Cheyne-Stokes  respiration,  in  brain  in- 
jury, 190 
Chilblain,  165 

Chimney-sweep's  cancer,  710 
Chloroform  anse^thesia,  1211 
Choked  disk  in  brain  injury,  190 
Cholecystectomy,  606 
Cholecystotomy,  605 
Cholelithotomy,  605 
Chondroma,  91 
Chopart's  amputation,  760 
Chordee,  700 
Chorea,  in  stumps,  749 
Chronic  abscess,  53 

ulcer,  57 
Chyluria,  683 
Cicatrices  of  neck,  treatment  of,  548 


INDEX. 


777 


Cicatricial    contraction,    prevention   of, 
164 
treatment  of,  165 
Cicatrix,  contractino;,  from  burns,  162 

keloid  in,  162 
Circulation,  collateral,  225 

in  lymphatics,  248  ' 

venous,  227 
Circumcision,  71S 
Cirsocele.     [See  Varicocele.) 
Cirsoid  aneurism.     [See  Arterial  varix.) 
Clamp,  for  hemorrhoids,  640 

for  resection  of  intestine,  599 

for  semilunar  dislocations,  514 
Clap.     [See  Gonorrhoea.) 
Clavicle,  dislocations  of,  491 

fracture  of,  381 

treatment  of,  383 
Clavus,  154 
Clitoris,  erection    of,  in  spinal  fracture, 

354 
Closed  ulcer,  53 

Cleeman's  test  for  femoral  fracture,  421 
Cleft  palate,  554 
Cloacfe  in  necrosis,  308 

of  bones,  309 
Clove-hitch  knot,  483 
Club-foot,  785 

bursse  upon,  181 

operative  treatment  of,  737 
Coagulation-necrosis,  60 
Coagulum,  225 
Cocaine  anaesthesia,  129 
Coccvgodvnia,  from  coccygeal  fracture, 

380 
Coccyx,  dislocations  of,  489 

fracture  of,  379 

coccygodynia  from,  380 
Cold  abscess,  53.     [See,  also,  Abscess.) 
Cold  in  inflammation,  46 
Colectomy,  699 
Colic,  renal,  662 
Collapse.     [See  Shock.) 
Collar-bone.     [See  Clavicle.) 
Collar  for  spinal  disease,  459 
Collateral  circulation,  225 
in  arteries,  282 
in  lymphatics,  248 
venous,  227 
Colles's  fracture.     [See  Radius,  fracture 

of.) 
Collodion  dressing,  142 
Colloma,  108 
Colon,  excision  of,  599 
Colotomy,  596 

Amussat's  method,  597 

inguinal.      [See  Laparo-colotomy.) 

in  stricture  of  reclum,  652 

Littre's  method,  598 

lumbar,  597 
Columella,  nasal,  absence  of,  554 
Columna  of  nose,  restoration  of,  533 
Compound  fractures.      [See  Open    frac- 
tures.) 
Compression  in  aneurism,  274  | 


Compression  in  inflammation,  47 

of  brain,  195 
Compressors,  arterial,  275 
Concussion  of  brain,  193 

of  spinal  cord,  203 
Condyle  of  lower  jaw,  excision  of,  519 
Condylomata,  77 
Congenital  deformities  of  joints,  446 

dislocations,  446 

hernia,  614 
Congestion,  33 

Constipation  in  strangulated  hernia,  616 
Continuous  suture  of  intestine,  600 
Contraction,  cicatricial,  164 

Dupuytren's,  174 
Contusion  of  brain,  193 

of  chest,  542 
Cord,  spinal,  concussion  of,  203 
contusion  of,  203 
inflammation  of,  200 
laceration  of,  V03 
wounds  of,  203 
Corns,  100,  154 

excision  of,  154 
Costal  cartilages,  dislocations  of,  513 

fractures  of,  372,  377 
Counter-irritation,  143 

by  blisters,  143 

b}'  cautery,  143 

in  inflammation,  47 
Cowper,  glands  of,  inflammation  of,  700 
Cowperitis,  700 
Coxalgia.       [See   Hip-joint,  tuberculosis 

of.) 
Coxitis.     [See  Hip-joint,  tuberculosis  of.) 
Cranial  fractures,  bleeding  from  ear  in, 

359 
Cranium,  fractures  of,  356 
treatment  of,  359 
trephining  in,  360 
Crepitation,  auscultation  of,  330 

in  fracture,  329 

in  thecal  cysts,  177 
Crepitus,  in  dislocations,  481 

in  fractures,  329 

in  thecitis,  171 
Cross-leg  deformity,  463 
Cupping  in  inflammation,  47 
Curette,  Barker-T^illard,  518 

irrigation,  518 
Curvature  of  spine,  antero-posterior.   [See 

Spondylitis.) 
Cutaneous  erysipelas,  64 
Cutting  oflp   blood-supply  in   inflamma- 
tion, 47 
Cyphosis.     [See  Spondylitis.) 
Cyrtometer,  Wilson's,  190 
Cyst,  thecal,  176 
Cystitis,  671 

acute,  671 

chronic,  672 

in  spinal  fracture,  354 
Cystocele,  vaginal,  671 
Cystoma,  110 
Cystoscope,  668 


778 


INDEX. 


Cystotomy^  perineal.  687 

supra-pubic  lateral,  087 
Cysts,  111 

congenital,  11 1 

hydatid,  111 

of  liver,  6o4 

of  jaw.  558 

of  kidney,  6G4 

of  manunaiy  glands.  7<3ti 

of  mouth,  556 

of  ovary,  608 

rupture  of,  610 
tapping  of,  610 

of  pancrea^J.  607 

of  spleen,  607 

of  thvroid  fjland.  550 


DEC.\LC"IFIED  bone  plates,  602 
Deformities  of  bladder,  congenital, 
668 
of  nasal  septum.  531 

operations  for,  532 
of  no-ie,  531 
Deformity  after  fracture  at  ankle.  437 
angular,  of  spine,  452 
cross- leg,  4')3 
division  of  muscles  in,  173 

of  tendons  in, 173 
from  mufcular  paralysis.  172 
from  nasal  fracture,  365 
from  spastic  parnlysi*,  172 
from  tenosynovitis,  171 
gunstock.  in  humeral  fractures,  3!»6 
immediate   correction    of.    after   te- 
notomy, 174 
in  dislocations,  480 
in  fractures,  328 
in  hip  disease,  463 
of  joints,  congenital.  446 
Deligation.     {See  Ligation.) 
Delirium,  febrile,  216 
nervous,  215 
traumatic,  215 
asthenic,  215 
inflammatory,  215 
septic,  215 
tremens,    mechanical    restraint    in, 
217 
traumatic.  214 
treatment  of,  217 
Demarcation,  line  of.  61 
Depressants  in  inflammation,  48 
Diaphoretics  in  inflammation,  48 
Diaphragm,  paralysis  of,  in  spinal  frac- 
ture, 355 
Diastasis,  325 

at  symphysis  pubis,  378 
Diathesis,  hemorrhagic,  227 
Diet,  in  inflammation,  4'.' 
Diff"use  cellulitis,  64 
Difl'used  abscess,  51, 
suppuration,  52 
Dilatation  of  female  urethra.  70!t 
of  oesophagus,  56'.< 


Dilatation  of  oesophagus  in  stricture.  568 
of  rectal  strictures,  651 
of  stomach    in    pyloric     cancer    or 

stricture,  584 
of  urethra,  702 

continuous,  702 
Dilated  a-sophagus,  .36<s 
Dilator  for  female  nrethrn.  708 
oesophageal,  56!' 

tracheal,  539 
urethral,  703  et  seg. 
Dinner-plate  incision  of  brea*t,  76'.i 
Diphtheritic  inflammation,  45 
Directi>r,  Levis's  hernia,  622 
Disarticulation.       (See     Amputation 

through  joints.) 
Disk,  choked,  in  brain  injury,  190 
Dislocation,  476 

congenital,  446 

crepitus  in,  481 

definition  of,  476 

deformity  in,  480 

false  joint  in,  47'.' 

in  hip  disease,  466 

of  ankle-joint,  512 

of  astragiilu«,  512 

of  atlas,  488 

of  axis,  488 

if  carpus,  502 

of  cartilages,  512 
costal,  512 
ensiform,  513 
semilunar,  523 

of  clavicle,  4'.il 

of  coccyx.  480 

of  elbow,  4".t'.t 

of  femur,  505 

of  fibula,  512 

of  hip-joint.  505 

of  humerus.  493 

of  jaw.  48U 

of  knee-joint,  511 

of  maxilla,  489 

of  metacarpal  bones,  503 

of  metatarsal  bones,  512 

of  muscles,  170 

of  patella,  511 

of  phalanges  of  han  i,  503 
of  toes,  512 

of  radius,  499,  -501 

of  ribs,  489 

of  scapula,  492 

of  shoulder,  493 

of  special  joints,  487  et  seq. 

of  sternum,  491 

of  tarsal  bones,  512 

of  tarsus,  512 
1  of  tendons,  170 

of  thigh,  505 

of  thumb,  504 

of  tibia,  511 

of  ulna,  499,  502 

of  vertebne,  487 

of  wrist-joint,  502 

old,  476 


INDEX. 


779 


Dislocation,  old,  treatment  of,  486 

pathology  of,  478 

prognosis  of,  482 

reduction  of,  484 
force  in,  485 

symptoms  of,  480 

treatment  of,  483 
Dissection  wounds,  1'22 
Diuretics  in  inflammation,  48 
Division  of  tendons.     (.See  Tenotomy.) 
Dorsal  dislocations  of  femur,  506 
Duuche  for  foreign  bodies  in  nose,  526 

for  nasal  disease,  528 
Drainage  in  amputations,  747 

in  empyema,  545 

in  suppurating  joints,  449 

of  abdominal  cavity,  573 

-tube  in  empyema,  545 
Drain-tubes,  abdominal,  573 

glass,  573 
Dressings,  140 

collodion,  142 

fixed.     [See  Gypsum  dressings.) 

gypsum,  344 

plaster-of-Paris,  344 
Drill,  bone,  524 
Dropsy  of  joints,  449 
Dry  gangrene,  60 
Duodenal  ulcer,  from  burns,  168 
Duodenostomy.     (.See  Intestinal  anasto- 
mosis.) 
Dupuytren's  contraction,  174 
Dura   mater,    fungus    of.     {See   Fungus 

cerebri.) 
Dysphagia,  from  aneurism,  367 

from  foreign  bodies    in   cBsophagus, 
564 

from  ossophageal  obstruction,  564 

in  retro-pharyngeal  abscess,  563 
DyspncKa,  from  foreign  bodies  in  esopha- 
gus, 564 

in  kyphosis,  732 

in  retro-pharyngeal  abscess,  563 

in  spinal  inflammation,  201 


EBUKiS'ATION  of  bone.     {See  Ostitis.) 
Ecchymosis  in  fractures,  331 
Ecraseur,  in  removal  of  tongue,  561 
Ectropion,  151 
Effusion,  pleural,  545 

purulent,  39,  51. 
Eiloides.     (-See  Elephantiasis.) 
Elbow-joint,  amputation  through,  752 

ankylosis  of,  after  fracture,  399 

dislocations  of,  499 

excision  of,  520 
Electricity,  burns  from,  161 

in  neuralgia,  208 

in  uterine  tumors,  608 
Elt^ctro-cautery,  143 
Elephantiasis,  Arabian,  160 

Grecian.  160 

of  scrotum.  710 

of  vulva.  725 


Elephantiasis,  treatment  of,  b}'  arterial 
ligation,  161 
by  nerve  section,  181 
Embolic  abscess,  66 
Embolism,  fat,  in  fractures,  333 
Embolus,  67 

venous,  67 
Emetics  in  inflammation,  48 
Emphvsema,    from    clavicular   fracture, 
'381 

in  chest  wounds,  544 

in  nasal  fractures,  365 

in  neck  wounds,  548 

in  wounds  of  oesophagus,  564 
Emprosthotonus  in  tetanus,  210 
Empyema,  treatment  of,  545 
Encephalitis,  183 
Encephalocele,  182 
Encephaloma,  108 
Enchondroma,  92 
Encysted  calculi,  679 
Endosliiis,  307 

Ensifuim  cartilage,  dislocation  of,  513 
Enterectomy,  599 
Entero-cholecystotomy,  606 
Enterocele,  614 
Entero-epiplocele,  614 
Enterorrhaphy,  586 
Enterotome,  594 
Enterotomy,  591. 
Enucleation.      (.See  Individual  organs  ; 

excisions.) 
Epididymis,  inflammation  of,  715 
Epididymitis,  715 
Epilepsy,  trephining  for,  363 

Jacksonian,  187 
Epiphyses,  acromial,  separation  of,  386 

fractures  of,  325 

of  humerus,  388 

separation  of,  325 
in  ostitis,  304 
Epiphysitis,  818 
Epiplocfle,  614 
Epistaxis,  526 
Epithelioma,  100,  108 

columnar,  110 

in  stumps,  749 

of  larj^ns,  537 

of  lip,  555 

of  oesophagus,  566 

of  penis,  722 

of  rectum,  652 

of  scrotum,  710 

of  tongue,  560 

of  vulva,  725 

squamous,  108 
Epulis,  557 
Erasion  of  joints,  515 
Erysipelas,  64 

cellular,  64 

cutaneous,  64 

in  burns,  163 

in  wounds,  64 

phlegmonous,  64 

simple,  64 


780 


INDEX. 


Erysipelas,  symptoms  of,  04 

tretitmeiit  of,  (i-j 
Erythema  nodosum,  249 
Eschar,  16'_' 
Esmarch's    avascularization    apparatus, 

745 
Estlander's  operation.     (See  Empyema, 

treatment  of.) 
Ether  ana?sthesia,  1:!0 
Evaciiator,  Bigelow's  litholapaxy,  080 
Exarliculation.       [See   Amputations    at 

joints.) 
Excision  for  ankylosis,  'jIO 

for  disea.'^e,  STo 

of  anivle-joint,  525 

of  carpal  bone.«,  521 

of  carpus,  521 

of  elbow-joint,  520 

of  Fallopian  tubes,  Glo 

of  hemorrhoids,  640 

of  hip-joint,  522 

anterior  method,  52o 
posterior  method,  522 

of  interphalangeal  joints,  522,  525 

of  intestine,  n'M 
in  hernia,  023 

of  jaw,  for  epithelioma  <>f  lip,  5-50 

of  joints,  515 

for  ankylosis,  472 
for  injury,  510 
method  of,  516 

of  kidney,  000 

of  knee-joint,  524 

of  loose  bodies  from  joints,  473 

of  mammary  glands,  709 

of  metacarpo-phalangetil  joints,  522 

of  metatarso-phalangeal  joints,  526 

of  metatarso-tarsal  joints,  525 

of  nerves,  in  neuralgia,  208 
in  tetanus,  212 

of  ovarian  cysts,  Oil 

of  penis,  728 

of  pylorus,  6So 

of  rectum,  (i5o 

of  ribs,  in  empyema,  540 

of  shoulder-joint,  519 

of  special  joints.      {See   Individual 
joints.) 

of  spermatic,  veins,  715 

of  spleen,  607 

of  tarsal  bones  in  club-foot,  737 

of  temporo-maxillary  joint,  519 

of  testicle,  717 

of  thyroid  gland,  650 

of  tongue,  560 

of  tonsils,  562 

of  tunica  vatfinalis,  713 

of  uterus,  OOS 

of  vermiform  appendix,  590 

of  wrist-joint,  520 
Exfoliation    of    bone,    309.     (.See,    also, 

Necrosis.) 
Exomphalos.     (.S'ee  Hernia,  umbilical.) 
Exophthalmic  goitre,  549 
Exostoses.     [See  Bones,  tumors  of.) 


Exostoses  in  osteo-arlhritis,  4(i8 
Exostosis,  93 

Exploration  of  abdomen,  572 
of  ffisophagus,  5()5 
of  stomach,  578 
of  urethra,  701 
Exploring  needle,  144 
Exstrophy  of  bladder,  069 
operations  for,  070 
urinal  for,  669 
Extension  apparatus,  342 

Indian  puzzle,  504 

Levis's,  for  finger  dislocations, 

504 
Morton's,  466 
Sayre's,  457 
of  inflammation,  40 
plate,  Levis's,  351 
.    vertical,  in  femoral  fractures,  429 
Extirpation.     {See  Excision.) 
Extravasation  of  blood,  221 
Extroversion  of  bladder,  609 
Exudation  in  inflammation,  38  et  seq. 
of  lyraph,  41 

Ij^ACE,  fracture  of  bones  of,  365 
Fallopian  tubes,  diseases  of,  012 
excision  of,  013 
inflammation  of,  612 
False  ankylosis,  470 

joint,  in  dislocations,  479 
Fascia   lata,    relaxaticn  of,    in    femoral 
fractures,  421 
jialmar,  contraction  of,  174 

division  of,  in  Dupuytren's  con- 
traction, 175 
Fat  embolism,  in  fractures,  333 
Fecal  fistule,  592 
Feces,  impaction  of,  in  rectum,  634 

incontinence  of,   in    spinal    inflam- 
mation, 201 
Femoral  artery.     {See  Artery.) 

hernia,  628 
Femur,  dislocations  of,  505 
anterior,  508 
backward,  500 
dorsal,  500 
forward,  508 

ileo-femoral  ligament  in,  505 
iliac,  506 
ischiatic,  500 
obturator,  508 
old,  510 
j  posterior,  506 

pubic,  509 
thyroid,  508 
fractures  of,  415  et  seq. 
capsular,  417 
I  cervical  absorption  in,  418 

epiphyseal,  410,  429 
I  extension  apparatus  for,  426 

AUis's  test  for,  421 
Cleeman's  test  for,  421 
ilorris's  test  for,  421 


INDEX. 


781 


Femur,  fractures  of,  impaction  of,  417 
of  condyles,  429 
of  neck,  416 
of  shaft,  425 
treatment  of,  424  et  seq. 
vertical  extension  in,  429 

section  of,  in  knock-knee,  742 
Fever,  aseptic,  of  wounds,  (Jo 

asthenic,  44 

inflammatory,  44 

sthenic,  44 

suppui-ative.     {See  PyiBa)ia.) 

surgical,  44.     [See,  also,  Pyajmia  ) 

symptomatic,  44 

traumatic,  44 

typhoid,  rupture  or  perforation   of 
intestine  in,  585 

urethral,  704 
Fibrin,  laminated,  in  aneurisms,  267 
Fibrinous  inflammation,  39 
Fibroma,  90 
Fibro-myoma,  95 
Fibula,  dislocations  of,  512 

fractures  of,  436 
Filiform  bougies,  704 
Fingers,  Dupuytren's  contraction  of,  174 

webbed,  734 
First  intention,  union  by.     (See  Union, 

primary.) 
Fissure  of  anus,  646 

of  Rolando,  localization  of,  189 
Fistula  or  fistule,  55 

anal,  643 

treatment  of,  645 

arterio-venous,  256 

biliary,  606 

fecal,  592 

of  vagina,  727 

recto-urethra],  646 

recto-vesical,  646 
treatment  of,  55 

recto-vaginal,  646,  727 

renal,  663 

salivary,  563 

urethral,  705 

urethro-vaginal,  727 

vesical,  674 

vesico-vaginal,  727 
Fixed  dressings.     (See  Dressings.) 
Flaps,  by  transfixion,  746 

in  Teale's  method  of  amputation,  748 

musculo-cutaneous,  747 
Flat-foot,  739 
Floating  kidney,  656 

operations  for,  656 
Fluctuation  in  abscess,  53 
Foot,  club,  735 

flat,  739 
Forceps,  bone,  516 

bone-cutting,  516 

gnawing,  362 

hemostatic,  126 

phimosis,  719 

rongeur,  362 

Stromeyer's,  491 


Forceps,  Tait's  cholelithotomy,  606 
Thornton's  T-shaped,  611 
urethral,  705 
Forearm,  amputation  of,  752 
fracture  of  bones  of,  400 
Foreign  bodies  in  air-passages,  534 

in  bladder,  680 

in  intestines,  584 
removal  of,  584 

in  nose,  526 

in  oesophagus,  564 

in  rectum,  634 

in  stomach,  579 

in  tongue,  560 

in  urethra,  705 

in  vagina,  728 

in  vermiform  appendix,  595 
Formation  of  pus,  50 
Frffirium  of  tongue,  short,  559 
Fragilitas  ossium.     [See  Osteomalacia.) 
Friction  in  inflammation,  47 
Fracture  bed,  337 
Fracture-box,  application  of,  439 
elevated,  441 
inclined  plane,  428 
suspension  of,  440 
Fracture  of  bones  in  stumps,  749 
of  penis.     {See  Eupture  of.) 
Pott's.     {See  Fibula,  fractures  of.) 
Fractures,  321 

blood  extravasation  in,  331 
causes  of,  321 
closed,  322 
comminuted,  323 
complete,  324 
compound  or  open,  322 

repair  of,  336 
crepitus  in,  329 
definition  of,  321 
deformed  union  in,  350 
deformity  following,  350 

in,  327 
delayed  union  in,  347 
diagnosis  of,  332 

differential,  332 
displacement  in,  326 
dressing  of,  339 
ecchymosis  in,  331 
epiphyseal,  325 

repair  of,  336 
extension  apparatus  for,  342 
fat  embolism  in,  333 
green-stick,  324 
gunshot,  of  joints,  347 
impacted,  323 

incisions  for  swelling  in,  338 
incomplete,  324 
into  joints,  treatment  of,  345 
method  of  examination  of,  327 
muscular  spasm  in,  331 
oblique,  324 
oedema  in,  333 
of  acetabulum,  379 
of  acromion,  386 
of  bones  of  face,  365 


782 


I  X  I)  E  X  , 


Fractures  of  bones  of  foot,  444 

of  forearm,  400 

near  elbow-joint,  4(^0 
of  carpal  bones,  413 
of  cartilages,  costal,  372 

nasal,  3()5 

repair  of,  336 
of  clavicle,  381 
of  coccyx,  370 
of  costal  carlilages,  377 
of  cranium,  3of5 

bleeding  from  ear  in,  3')9 

escape  of  cerebro-spinal  fluid  in, 
359 

paralysis  in,  350 
of  epiphyses,  325 
of  femur,  415 

condyles,  420 

head  and  neck,  416 

shaft,  42."> 
of  fibula,  430 
of  humerus,  condyloid,  304 

lower  extremity,  303 

supra-condyluid,  304 

upper  extremity,  301 
of  hyoid  bone,  370 
of  ilium,  370 
of  innominate,  378 
of  ischium,  378 
of  jaw,  lower,  366 

upper,  365 
of  joints,  345 
of  larynx,  370,  534 
of  malar  bone,  366 
of  malleolus,  438 
of  maxillary  bunes,  366 
of  metacarpal  bones,  413 
of  metatarsal,  bones,  445 
of  nasal  bones,  365 
of  nose,  365 
of  olecranon,  400 
of  patella,  431 
of  pelvic  hones,  377 
of  pelvis,  377 
of  phalanges  of  fingers,  414 

of  toes,  445 
of  pubis,  378 
of  radius,  403,  406 
of  ribs,  374 
of  sacrum,  378 
of  scapula,  385 
of  skull,  356 
of  special    bones.     {See   Individual 

bones.) 
of  spine,  352 
of  tar.>al  bones,  444 
of  tibia,  436 
of  trachea,  534 
of  ulna,  405 
of  vertebrje,  352 
of  zygoma,  366 
open,  322 

or  compound,  treatment  of,  345 
amputation  for,  346 
pathology  of,  325 


Fractures,  preternatural  mobility  in,  328 

prognosis  of,  333 

reduction  of,  .■'38 

repair  of,  334 

retention  of  urine  in.  313 

setting  of,  337 

simple,  322 

special,  3-52 

splints,  340 

sprain,  325 

stiffness  after,  333 

swelling  in,  331 

symptoms  of,  327 

constitutional,  332 

transverse,  324 

treatment  of,  336  et  seq. 

air  and  water  beds  in,  337 
beds  for,  337 
extension  in,  341 
transportation  in,  337 

ununited,  347 

treatment  of,  348 

Van  Wagenen's  dressing  for,  443 

varieties  of,  322 

vicious  union  in,  850 
Frontal  sinus,  abscess  of,  534 
Frostbite,  165 

erytheuuitous,  165 

necrotic,  166 

treatment  of,  1(50 

vesicular,  165 
Functional  changes  in  inflammati<  n,  44 
Fungous  ulcer,  57 
Fungus  cerebri,  102 

of  brain,  192 
Furuncle,  155 
Furunculosis,  155 


GALL-BLADDER,  fistule  of,  606 
incision  of,  605 

wounds  and  injuries  of,  604 
Gall-duct,  obstruction  of,  605 
Gall-stones,  removal  of,  605 
Galvano-puncture  in  neuralgia,  208 
Ganglion,  176 

compound,  177 
Gangrena    oris.      [See    Stomatitis,   gan- 
grenous.) 
Gangrene,  45,  50 

amputation  for,  63 

causes  of,  60 

dry,  60 

from  tight  bandaging,  343 

hospital,  63 

in  aneurism,  267 

line  of  demarcation  in,  61 

moist,  60 

of  bone.     [See  Necrosis.) 

of  intestine  in  hernia,  616 

pulmonary',  547 

senile,  61 

symptoms  of,  60 

treatment  of,  62 
incisions  in,  62 


INDEX 


783 


Gangrene,  varieties  of,  60 

Gangrenous  stomatitis.     {See  Stomatitis.) 

ulceration,  63 
Gaping,  dislocation  of  jaw  from,  489 
Gastro-enterostomy,  584,  602 
Gastrorrhaphy,  583 
Gastrostomy,  580 

feeding  after,  582 
Gastrotomy,  582 
Gathering.     [See  Abscess.) 
Genital  organs,  diseases  and  injuries  of 

710 
Genu-valgura,  740 
Genu- varum,  740 
Gladiolus,  fractures  of,  371 
Glanders,  122 

Glands,  axillary,  infiltration  of,  in  mam- 
mar}-  carcinoma,  767 

cervical,  infiltration  of,  in  mammary 
carcinoma,  767 
inflammation  of,  548 
tuberculosis  of,  548 

lymphatic,  inflammation  of,  250 

mammary,  disease-:  of,  763 

vulvo-vaginal,  inflammation  of,  724 
Glottis,  cedema  of,  534 
Glass  liquid.     [See  Sodium  silicate.) 
Gleet,  699 
Glioma,  104 
Glossitis,  559 

syphilitic,  559 
Glottis,  scarification  of,  534 
Goitre,  548 

excision  of,  550 

exophthalmic,  549 
Gonococci,  699 
Gonorrhoea,  698 

chronic,  699 

complications  of,  700 
Gonorrhoeal  arthritis,  450 

urethritis,  698 

in  the  female,  698 
Grafting  of  bone,  311 

of  trephine  buttons,  364 
Grafts  of  omentum,  in  abdominal  opera- 
tions, 600 
Granny  knot,  137 
Granulating  surfaces,  union  of  apposed, 

164 
Granulation,  117 

and  cicatrization,  117 

changes  in,  39 

healing  by,  117 

tissue,  39 
Gravel.     [See  Calculus,  vesical.) 
Graves's  disease.    [See  Goitre,  exophthal- 
mic.) 
Green-stick  fractures,  324 
Gum,  abscess  of,  557 

diseases  of,  556 

lancing  of,  557 
Gum -boil,  557 
Guillotine,  for  tonsils,  562 
Gullet.     (See  (Esophagus.)' 
Gumma,  of  tongue,  560 


Gumma,  syphilitic,  78 
Gunshot  wounds,  123 

of  abdomen,  571 
Gunstock  deformity,  397 
Gurgling  in  hernia",  616 
Gustatory  nerve,  division  of,  in  lingual 

cancer,  560 
Gypsum  bandages,  344 

dressings,  344 

splints,  341 

HAIE,  falling  of,  in  syphilis,  77 
Hand,  amputation  of,  753 
Hard  cancer.   [See  Carcinoma,  scirrhous.) 

chancre.     [See  Chancre,  syphilitic.) 
Harelip,  552 

operations  for,  553 

suture,  137 
Heart,  wounds  of,  219 
suture  of,  220 
Hemato-salpinx,  612 
Hematuria  in  kidney  injuries,  664 
Hemarthrosis,  448 
Hematocele  of  tunica  vaginalis,  713 
Hematoma,  arterial,  252 

of  vulva,  724 
Hematophilia,  227 
Hematuria,  682 
Hemoirhage,  221 

anemia  from,  223 

arrest  of,  Nature's  method,  224 

arterial,  222 

bandaging  of  limbs  in,  227 

capillary,  222 

causes  of,  222 

cerebral,  186 

checking  of,  permanent  means,  225 
temporary  means,  224 

compression  of  aorta  in,  227 

constitutional  eflects  of,  222 

during  operations,  135 

from  ear  in  cranial  fracture,  359 

from  intercostal  artery,  543 

from  nose,  526 

from  tonsils  after  excision,  562 

from  uterus,  607 

from  venous  sinuses  in  trephining, 
364 

intermediary,  221 

intermeningeal,  186 

into  cerebral  ventricles,  186 

ligation  of  arteries  in,  232 

parenchymatous,  222 

primary,  221 

secondary',  221 

amputation  in,  239 
treatment  of,  237 

subcranial,  186 

subcutaneous,  221 

traumatic,  221 

treatment  of,  227 

bloodletting  in,  228 
cautery  in,  230 
constitutional,  227 


784 


INDEX. 


Hicmorrhaire,  treatment  of,  hot  water  in, 

local,  2'1'.\ 
pressure  in,  2;)0 
rubber  bandaiie  in,  '2ol 
styptics  in,  2;i0 
tourniquet  in,  '2'-\\ 

varieties  of,  221 

venous,  222,  289 

treatment  of,  240 

vicarious,  222 
Hemorrhaijic  diathesis,  227 
Hemorrhoids,  Do? 

bleeding  from,  6o8 

external,  (ill 

hemorrhase  from,  688 

internal,  6o7 

cedemalous,  042 

operalicms  for,  Go'.i 

urethral,  70<; 
Hemostatic  forceps,  12(5 
Hepatic  duct,  obstruction  of,  605 
Hepatotomy,  604 
Hermai)hr(>dism,  710 
Hernia,  618 

causes  of,  61:'. 

congenital,  (il4 

diaphragmatic,  614 

director,  Levis's,  622 

femoral,  628 

gangrene  of,  616 

of  intestine  in,  616 

incarcerated,  615 

incomplete,  625 

inflamed,  614 

inguinal,  624 

irreducible,  615 

obstructed,  615 

obturator,  614 

of  brain.     (.S'ee  Fungus  cerebri.) 
congenital,  182 

of  muscles,  16'.i 

pathology,  614 

radical  operations  upon,  610 

reducible,  614 

sac  of,  614 

strangulated,  620 

strangulation  of,  615 

symptoms  of,  616 

taxis  in,  620 

treatment  of,  617 

trusses  for,  617 

umbilical,  6:!0 
Herniotomy,  621 
Herpes  of  lip,  555 

of  penis,  721 
Hey's  amputation,  761 
High  operation  for  stone.     (.See  Lithot- 
omy, suprapubic.) 
Hip  disease.     [See  Tuberculosis  of  hip- 
joint.) 
Hip-juint,  amputation  through,  754 

dislocations  of,  505 

excision  of,  522 

anterior  method,  522 


Hip-joint,  amputation  through,  posterior 
method,  522 
tuberculosis  of,  461 
diagnosis  of,  461 
syin|)toms  of,  462 
treatment  of,  464 
Hodgliin's  disease,  95,  251 
Hollow  back,  782 
Hooks,  patellar,  484 
Horner's  awl,  254 
Hospital  gangrene,  68 
Housemaid's  knee,  17'.t.     (S'ee,  <tlso.  Bur- 
sitis.) 
Humerus,  dislocations  of,  4".i8 
diagnosis  of,  4116 
downward,  498 
subclavicular,  495 
subcoracoid,  495 
subglenoid,  498 
subspinous,  495 
treatment  of,  497 
varieties  of,  493 
fractures  of,  ;!87  et  seq. 
Hunter's  method  of  ligation,  279 
Hydatid  cysts,  111 
Hydrarthrosis,  449 

Hydrence[)hal(K'ele.     (-S'ee  Meningocele.) 
Hydrocele  in  the  female,  718 
of  canal  of  Nuck,  713 
of  neck,  congenital,  548 
of  spermatic  cord,  718 
of  tunica  vaginalis,  711 
acquired,  711 
congenital,  711 
incisionand  drainage  of,  718 
injection  of,  712 
loose  bodies  in,  711 
tapping  or  aspiration  of,  712 
treatment  of,  radical,  712 
Hydrocephalus,  182 
acute,  182 
aspiration  of,  188 
puncture  of  ventricles  in,  188 
I  treatment  of,  188 

I  Hydrogen  test,  Senn's,  571 
I  Hydro-nephrosis,  656 
intermittent,  657 
treatment  of,  657 
Hydrophobia,  212 

treatment  of,  214 
Hydrops  articuli.     (-See  Hydrarthrosis.) 
I  Hydrorachis,  198.  (.See aZso  Spina  bifida.) 
I  Hydrothorax.     (.S'ee  Pleural  effusion.) 
aspiration  of,  545 
Hyoid  bone,  fracture  of,  870 
Hyperemia,  88, 

inflammatory,  84 
Hyperdistenlion  of  abscesses,  54 
Hyperinosis  of  blood,  41 
Hyperpyrexia  in  tetanus,  210 
Hypertrophy  of  bone,  818 

of  tonsils,  562 
Hysterectomy,  608 

vaginal,  608 
Hysteria  of  joints,  470 


INDEX. 


785 


TCE.     (See  Cjld.) 
1     Idiopathic  inflammation,  34 
Ileo-colotomy,  620 

Ileo-femoral   ligament,   in    hip    disloca- 
tions, 505 
Iliac  artery.     {See  Artery.) 
dislocations,  506 
of  femur,  507 
Ilium,  fracture  of,  379 
Impaction  of  feces  in  rectum,  634 
Imperforate  anus,  632 

rectum,  632 
Impulse  in  coughing  in  hernia,  616 

in  varicocele,  714 
Incision,  dinner-plate,  of  breast,  769 
Incisions  in  general,  128 
Incontinence  of  feces  in  spinal  injuries. 
[See  Spine,  injuries  of.) 
of  urine,  682 

in  spinal  injuries.     (See  Spine, 
injuries  of.) 
Indian  method  of  rhinoplasty,  538 

puzzle,  504 
India-rubber  rings    for  intestinal  anas- 
tomosis, 602 
Indolent  ulcer,  57.     (See  also  Ulcer.) 
Induration    of  chancre.     (See   Chancre, 

hard  and  soft.) 
Infantile  hernia.     [See  Hernia,  congeni- 
tal.) 
Infiltration,  purulent.  39,  51 
Inflamed  hernia,  620 
Inflammation,  33 
bljod  in,  41 
bloodvessels  in,  40 
causes  of,  34 

constitutional  symptoms  of,  44 
definition  of,  33 
diphtheritic,  45 
discoloration  in,  43 
disordered  function  in,  44 
extension  of,  40 
fibrinous,  39 
general  symptoms  of,  44 
idiopathic,  34 
metastatic,  40 
microorganisms  of,  37 
nerves  in,  40 
of  arteries,  259 
of  bladder,  671 
of  bones,  304 
of  cervical  glanls,  548 
of  epididymis,  715 
of  epiphyseal  cartilages,  318 
of  Fallopian  tubes,  612 
of  glands  of  Cowper,  700 
of  kidney,  658 
of  lymphatic  glands,  250 
of  lymphatics,  248 
of  mammary  glands,  763 
of  nerves,  203 
of  oesophagus,  565 
of  penis,  720 
of  periosteum,  302 
of  peri-renal  tissues,  659 


Inflammation  of  rectum,  633 
of  spinal  cord,  200 
of  testicle,  715 
of  theca,  170 
of  tongue,  559 
of  urethra,  698 
of  vagina,  727 
of  veins,  242 

of  vermiform  appendix,  594 
of  vulva,  724 
pain  in,  42 
pathology  of,  40 
productive,  39 
redness  in,  43 
resolution  of,  45 
results  of,  45 
serous,  38 
suppurative,  39 
symptoms  of,  42 
temperature  in,  43 
terminations  of,  45 
tissues  in,  42 
traumatic,  34 
treatment  of,  45  et  seq. 
alteratives  in,  49 
anodynes  in,  47 
antiseptics  in,  47 
astringents  in,  47 
cathartics  in,  48 
cold  in,  46,  48 
compression  in,  47 
constitutional,  48 
counter-irritation  in,  47 
cupping  in,  47 

cutting  off  arterial  supply  in,  47 
depressants  in,  48 
diaphoretics  in,  48 
diet  in,  49 
diuretics  in,  48 
emetics  in,  48 
friction  in,  47 
heat  in,  46 
leeching  in,  47 
local  blood-letting  in,  47 
massage  in,  47 
necrotics  in,  47 
position  and  rest  in,  46 
sanitary  measures  in,  49 
specifics  in,  49 
stimulants  in,  47 
tonics  in,  48 
venesection  in,  48 
Inflammatory  blood,  41 
exudate,  41 
fever,  44 
lymph,  41 
swelling,  43 
Ingrowing  toe-nail,  167 
Inguinal  hernia,  624 
Injection  of  abscesses,  55 

of  hydrocele,  712 
Innominate  bone,  fracture  of,  378 
Inoculation  of  rabies,  214 
Insects,   stings  of.     {See   Wounds,   poi- 
soned.) 
50 


786 


INDEX. 


Instrument?.     (See  Various  operations.) 

cleaiisine;  of,  127 

general  consideration  of,  126 

sterilization  of,  128 
Intercostal  artery,  heniorrhace  from,  54:) 
treatnuMit  of,  CA-] 
laceration  of,  in  rih  fractures,  :>7-> 
Intestinal  anastomosis,  002 

obstruction,  587 

wounds,  585 
Intestine,  excision  of,  590 

foreign  bodies  in,  584 

internal  strangnlatii  n  of,  589 

obstruction  of,  from  stricture,  589 

operations  upon,  591 

perft)rating  ulcer  of,  585 

resection  of,  in  hernia,  623 

rupture  of,  585 

stricture  of,  589 

suture  of,  586 

tumors  of,  591 

wounds  of,  584 

gunshot  and  stab,  584 
Intervertebral  joints.     (.See  Vertebra-. ) 
Intoxication,  septic,  65 
Inlrapvretic    amputation.     (See    Ampu- 
tation, secondar}-.) 
Intubation  of  larynx,  541 
Intussusception,  588 
Intussusccplum,  588 
Inlussuscipiens,  588 

Invagination  of  intestine.     (See  Intus- 
susception.) 

of  sequestra.     (See  J^ecrosis.) 
Involucrum  of  bone,  ol2 
Irrigation,  curette,  518 

of  abdominal  cavity,  573 

of  pleural  cavity,  546 
Ischialic  dislocations  of  femur,  .506 

notch  or  foramen,  dislocation  into, 
506 
Ischio-rectal  abscess,  642 
Ischium,  fracture  of,  o78 
Italian  method  of  rhinoplasty,  533 


JACKET,  leather,  458 
plaster,  application  of,  457 
Jacksonian  epilepsy,  187 
Jaw,  cysts  of,  558 

dislocations  of,  489 

excision  of,  for  epithelioma  of  lip, 

556 
fracture  of,  306  et  seq. 
locked.     (.See  Tetanus.) 
necrosis  of,  558 
tumors  of,  557 
Jejuno-ileostomy,  602 
Joints,  abscess  of,  449 

amputation    through,       (.See    Indi- 
vidual joints.) 
ankylosis  of,  470.     (.See  also  Ankj-- 

losis.) 
aspiration  of,  515 
changes  in,  in  locomotor  ataxia,  469 


Joints,  Charcot's  disease  of,  469 
contusions  of,  473 
deformities  of,  conuenital,  446 
dropsy  of,  449.     (.See  also   Hydrar- 
throsis.) 
efi'usion  into,  449 
erasion  of,  515 

excision    of,    515.     (.S'ec   also    Indi- 
vidual joints;  excisions,) 

for  ankylosis,  516 

for  disease,  516 

for  injury,  516 

method  of,  516 
exploration  of,  515 
false,  in  dislocations,  479 
fractures  into,  icpair  of,  336 

treatment  of,  345 
gunshot  fractures  of,  847 
hemorrhage  into,  448 
hy^teria  of,  470 
inflammation   of.      (.S'ee   Synovitis; 

arthritis.) 
injuries  of,  473 
irrigation  of,  515 
loose  bodies  in,  472 
neuralgia  of,  470 
operations  upon,  515 
scrofula  of.     (.S'ee  Arthritis,   tuber- 
cular.) 
sprains  of,  474 
stitf.     (See  Ankylosis.) 
suppurating.     (.See  Arihritis,  suppu- 
rative.) 
syphilis  of,  467 
tuberculosis  of,  450 

special,  451 
tumor.s  of,  448 
wounds  of,  474 


K 


ELOID,  in  burn  cicatrices,  162 
Kidney,  abscess  of,  6.38 

tubercular,  660 
aspiration  of,  665 
calculi  in,  661 

fistula;  from,  663 
congenital  malformations    and    dis- 
placements of,  655 
cysts  of,  664 
excision  of,  666 

incision  of.     (.See  Nephrotomy.) 
methods  of  examination,  655 
movable  or  floating,  656 
movable,  suture  of.     (.S'ee  Nephror- 

rhaphy.) 
simple  misplacement  of,  656 
suppuration  in,  658 
tuberculosis  of,  660 
tumors  of,  663 
wounds  of,  664 
Knee,    diseases   and   injuries    of.      (.S'ee 
Kine-joint.) 
housemaid's  179 
Knee-joint,  amputation  through,  757 
dislocations  of,  511 


INDEX. 


787 


Knee-joint,  excision  of,  524 
Knee-pan.     [See  Patella.) 
Knife,  lithotomy,  688 

tenotomy,  173 
Knives,  126 
Knock- knee,  740 
Knot,  clove-hitch,  483 

noose,  484 

Staffordshire,  612 
Kyphosis,  731 


T  ACERATIOX  of  brain,  193 
Ju         of  perineum,  725 
Laparo-colotomy,  598 
Laparotomy,  572 
Laryngectomy,  537 
Laryngotomy,  537 
Larynx,  epithelioma  of,  537 
excision  of,  537 
foreign  bodies  in,  534 
fracture  of,  370,  534 

tracheotomy  iii,  371 
intubation  of,  541 
tuberculosis  of,  536 
tumors  of,  536 
Lateral  anastomosis.     (See  Anastomosis, 
intestinal.) 
spinal  curvature,  731 
Laughing  gas.     [See  Nitrous  oxide.) 
Lavage  of  stomach,  570 
Leather  jacket  for  spine  disease,  458 
Leeches,  143 

in  inflammation,  47 
Leg,  amputation  of,  757 
Leio-myoma,  95 
Lembert's  suture,  586 
Leucoma,  560 

Levis's    extension    apparatus    for    finger 
dislocations,  504 
plate,  351 
patella  hooks,  434 
pulley,  427 

splint  for  fracture  of  radius,  411 
Ligament,  ileo-femoral,  in    hip  disloca- 
tions, 505 
Y.     [See  Ligament,  ileo-femoral.) 
Ligaments,  laceration  of.     {See  Sprains.) 
Ligation  of  arteries,  Anel's  method,  280 
of  arteries,  Brasdor's  method,  2S1 
calcareous,  262 
distal,  281 

for  elephantiasis,  161 
for  hemorrhage,  232 
Hunter's  method,  279 
in  aneurism,  279 
in  continuity,  285 
in  lingual  cancer,  560 
in  secondary  hemorrhage,  238 
proximal,  280 
Wardrop's  method,  281 
of  hemorrhoids,  640 
of  varicose  veins,  246 
of  veins,  240 

spermatic,  714 


Ligations  in  aneurism,  279 

complications  from,  282 
contra-indications  for,  282 
gangrene  in,  284 
indications  for,  282 
pyemia  in,  284 

secondary  hemorrhage  in,  284 
suppuration  of  sac  in,  284 
Ligature,  138, 232 

method  of  tying,  232 
varieties  of,  232 
Line  of  demarcation,  61 
Lingual  nerve,  division  of,    in    lingual 

cancer,  560 
Lip,  chancre  of,  555 
epithelioma  of,  555 
hare-,  552 
herpes  of,  555 
lupus  of,  555 

tuberculosis  of.     [See  Lupus.) 
Lipoma,  90 

Lips,  operations  upon,  151 
Liquid  glass.     (.S'ee  Sodium  silicate.) 
Lisfranc's  amputation,  761 
Lister's   wound   treatment.     {See   Anti- 
sepsis.) 
Lithectasy.      {See    Calculus,  in    female 

bladder.) 
Lithoclysmy.      {See     Calculus,    solvent 

treatment  of.) 
Litholapaxy,  683 

Bigelow's  apparatus  for,  687 
Litholysis.     {See  Calculus,  solvent  treat- 
ment of.) 
Lithotomv  knife,  688 
lateral,  687 
position,  687 
staff,  688 
Lithotrite,  684 

Bigelow's,  684 
Lithotrity,  683 

Littre's  method  of  colotomy,  598 
Liver,  abscess  of,  603 
hydatid  cysts  of,  604 
operations  upon,  604 
tumors  of,  604 
wounds  of,  603 
Lobster-tailed  trachea  tube,  541 
Lock-jaw.     {See  Tetanus.) 
Loose  bodies  in  joints,  472 

excision  of,  473 
in  tunica  vaginalis,  711 
Lordosis,  732 
Lower  jaw.     (-See  Jaw.) 
Lung,  incision  into,  547 

wounds  of,  543 
Lupus,  71,  158 
of  lip,  555 
of  vulva,  725 
Luxation.     (.See  Dislocation.) 
Lymph,  exudation  of,  41 

inflammatory,  41 
Lymphadenitis,  250 

of  cervical  glands,  548 
septic,  251 


788 


INDEX, 


Lymphadenitis,  tubercular,  '250 
Lyniphadenonia,  251 
Lymphancjeioma,  251 

cavernous,  97 

treatment  of,  100 
Lymphangitis,  248 

Lj-mphatic  glands,  inflammation  of,  250 
Lymphatics,    collateral    circulation    in, 
248 

diseases  of,  247 

inflammation  of,  248 

varicose,  251 

wounds  of,  247,  252 
Lymphoma,  04 

malignant,  05,  251 
Lymphorrhagia,  252 


MALAR  bone,  fracture  of,  366" 
Malformations.       (See    Deformity  ; 
Congenital  affections ;  Ortho- 
pedic suri;;ery.) 
special.    (See  Individual  parts.) 
Malgaigne's  patella  hooks,  484 
Malignant  pustule,  122 
Malleolus,  fractures  of,  438 
Mammary  abscess,  764 

glands,  abscess  of,  764 
diseases  of,  762 
excision  of,  760 
inflammation  of,  7(53 
Paget's  disease  of,  765 
tumors  of,  766 
Mammitis,  763.     (.See  also  Mastitis.) 
Manubrium,  fractures  of,  371 
Marriage  of  syphilitic.*,  75 
Massage  in  club-foot,  736 

in  inflammation,  47 
Mastitis,  763 

chronic,  764 
tuberculous,  764 
Maxilla.     {See  Jaw.) 

dislocations  of,  480 
Maxillary  bones,  fracture  of,  366  et  seq. 
Mediastinum,  abscess  of,  547 

tumors  of,  547 
Meigs-Case  suspension  chair,  459 
Melon-seed  bodies,  176 
Meninges,  congenital  tumors  of,  182 
Meningitis,  183 
spinal,  200 
Meningocele,  182 

spinal,  199 
Menopause,  artificial,  608 
Menses,  retained,  727 
Merocele.     (See  Hernia,  femoral.) 
Metacarpal  bones,  dislocations  of,  503 

fractures  of,  413 
Metacarpus,  fractures  of,  413 
Metapj^retic  amputation.     (See  Amputa- 
tion, intermediate.) 
Metastasis,  of  gonorrhoea  to  joints,  450 
Metastatic  abscess,  53,  66 

inflammation,  40 
Metatarsal  bones,  dislocations  of,  512 


Metararsal  bones,  fracture  of,  445 
Metatarsus,  fractures  of,  445 
Microorganisms  of  inflammation,  37 

of  suppuration,  50 
Morbus  senilis.     (See  Osteo-arthritis.) 
Moist  gangrene,  60 
MoUites  ossium,  319 
Morbus  coxie,  or  coxarius.     (See   Hip- 
joint,  tuberculosis  of.) 
Morris's  test  for  femoral  fracture,  421 
Mortification,  50 
Morton's  extension  apparatus,  466 

fractured  rib  corset,  376 
Motor  neuritis,  204 
Mouth,  chancre  of,  559 

cysts  of,  556 

diseases  of,  552 

tumors  of,  556 
Mucous  patches,  77 

ulcers,  treatment  of,  59 
Murmur,  aneurismal,  269 
Muscles,  dislocation  of,  170 

division  of,  for  deformity,  173 

hernia  of,  169 

rupture  of,  169 

section  of,  in  torticollis,  730 

spasm  of,  in  fractures,  331 
tenotomy  in,  174 

suture  of,  169 

wounds  of,  169 
Muscular    paralvsis,   deformities    from, 

172 
j  Myelitis,  200 
Myelocele,  199 
Myoma,  05 

fibrous,  05 
:  Myosuture,  169 
Myotomy,  173 

for  torticollis,  730.   (.^ee Tenotomy.) 
Myxoedema,  548 
Myxoma,  93 

of  bladder,  675 

of  nasal  chambers,  529 


vr^vi,  96 

li      treatment,  97 
Xaevus  maternus,  96 
Nail,  toe,  ingrowing,  167 
Nares.     (,S'ee  Nostrils.) 

plugging  of,  527 
Narrowing  rectum  for  prolapsus,  636 
Nasal  bones,  fr.icture  of,  365 

cartilages,  fracture  of,  365 

catarrh,  528 

polyps,  529 

tumors,  529 
Navel.     (See  Umbilicus.) 

ruptured.     (.S'ee  Hernia,  umbilical.) 
Neck,  congenital  cysts  of,  548 

diseases  of,  547 

hydrocele  of,  548 

wounds  of,  547 
Neck,  wry,  729 
Necrosis,  45 


INDEX, 


789 


Necrosis,  pyaemia  in,  310 
superficial,  308 
cloacae  in,  308 
coagulation-,  60 
in  tenosynovitis,  179 
of  bones,  307 

after  amputation,  309 
central,  308 
operations  for,  311 
pathology  of,  308 
prognosis  of,  310 
symptoms  of,  309 
total,  308 
treatment  of,  310 
of  jaw,  558 
of  stumps,  749 
phosphorus,  558 
Necrotics  in  inflammation,  47 
Needle,  exploring,  144 
Needles,  126 
Nelaton's  line,  421 

probe,  124 
Nephrectomy,  666 

abdominal  or  anterior,  667 
lumbar  or  posterior,  667 
Nephritic  colic,  682 
Nephritis,  suppurative,  658 

tubercular,  660 
Nephro-lithotomy,  666 
Nephrorrhaphy,  665 
Nerve,  lingual,   division   of,  in   lingual 
cancer,  560 
gustatory,    division    of,    in    lingual 
cancer,  560 
Nerve-stretching,  208 
in  neuralgia,  208 
in  neuritis,  205 
in  tetanus,  212 
Nerves,  division  or  excision  of,  209 
inferior  dental,  209 
infra-orbital,  209 
in  tetanus,  212 
supra-orbital,  209 
trifacial,  209 
inflammation  of,  203 
in  inflammation,  40 
injuries  of,  205 
reunion  of  divided,  205 
section  of,  for  elephantiasis,  161 
spinal  accessory,  stretching  and  di- 
vision of,  in  torticollis,  730 
suture  of,  206 
transplantation  of,  206 
wounds  of,  205 
Neuralgia,  206 

from  cicatricial  pressure,  206 
in  aneurism,  267 
of  joints,  470 
of  mammarj^  glands,  763 
reflex, 207 
Neurectomy,  208 
in  tetanus,  212 
palsy  after,  208 
Neuritis,  203 

cautery  in,  205 


Neuritis,  chronic,  204 

motor,  204 

nerve-stretching  in,  205 

sensory,  204 
Neuroses  of  mammary  glands,  763 

vesical,  674 
Neuroma,  96 
Neurotomy,  208 

for  neuralgia,  208 
Nipple,  Paget's  disease  of,  765 
Nitrous  oxide  anaesthesia,  129 
Noma.     (.See  Stomatitis,  gangrenous.) 
Noose  knot,  484 

Normal    ovariotomy.       [See   Oophorec- 
tomy.) 
Nose,  deformities  of,  531 

foreign  bodies  in,  526 

fracture  of,  365 

hemorrhage  from,  526 

reconstruction  of,  151,  533 

tip-tilted,  or  turned  up,  531 

tumors  of,  529 
Nostrils.     [See  Nares.) 
Nuck,  canal  of,  hydrocele  of,  713 


ABSTEUCTION,  intestinal,  587 
\J         of  bowels  in  rectal  stricture,  650 
Obturator  dislocations  of  the  femur,  508 
Occipito-atloid  dislocations,  488 
Occlusion.       (fS'ee  Imperforate ;    obstruc- 
tion.) 
of  anus.     [See  Anus,  imperforate.) 
of  arteries.     [See  Artery.) 
OEdema  of  glottis,  634 
CEdematous  swelling,  43 
(Esophageal  bougie,  569 

introduction  of,  569 
CEsophagismus,  567 
CEsophagostomy,  566 
OEsophagotomy,  566 
external,  569 
in  lingual  cancer,  560 
internal,  569 
(Esophagus,  auscultation  of,  568 
dilatation  of,  569 
dilated,  567 
epithelioma  of,  566 
exploration  of,  565 
foreign  bodies  in,  564 
inflammation  of,  565 
rupture  of,  564 
spasm  of,  567 
stricture  of,  567 
cicatricial,  -567 
organic,  567 
tumors  of,  566 
wounds  of,  564 
Old  dislocations,  486 
of  femur,  510 
of  humerus,  498 
treatment  of,  486 
Olecranon,  fracture  of,  400 
Omentum,  grafts  of,  in  abdominal  opera- 
tions, 600 


790 


INDEX. 


Omentum,  tumors  of,  5'.>1 
Omphalocele.       (See  Hernia,  umbilical.) 
Onychia,  If!? 
Onychitis,  166 
Oopliorectomy,  61:1 
Open  fractures,  treatment  of,  Mo 
Opening  an  abscess.    (See  Abscess,  treat- 
ment of.) 
Operation,  preparation  for,  183 
Operations,   constructive.      (.See   Plastic 
surgery.) 

plastic,  146 

upon  intestines,  591 

upon  joints,  SI*) 
Operative  method,  135 
Opisthotonos  in  tetanus,  210 
Orchitis,  716 

Organic  stricture.     (•S'ee  Stricture.) 
Orthopedic  surgery,  7*2'J 
Oateo-arthritis,  468 
Osteoclast,  351 
Osteomalacia,  319 
Osteoma,  93 
Osteomyelitis,  304 

central,  307 

cortical,  307 

infective,  306 

in  stumps,  749 
Osteophytes,  93 
Osteotomy,  741 

Adams's  saw  for,  517 

for  ankylosis,  472 
Ostitis,  304 

deforming,  304 

rarefying,  303 

symptoms  of,  305 

treatment  of,  306 

periosteal  incision  in,  307 
trephining  in,  307 
Ovarian  cysts,  608 
Ovariotomy,  611 

normal,  613 

trocar,  61 1 
Ovary,  cysts  of,  608 

rupture  of,  610 

tumors  of,  608 
Ozaena,  529 


PAGET'S  disease  of  nipple  and  mam- 
mary gland, 765 
Painful  ulcer  of  anus.    (See  Anus,  fissure 

of.) 
Palate,  cleft,  554 

age  for  operation,  555 
defects  of,  554 
Palmar  fascia,  contraction  of,  174 
Panaris.     {.S'ee  Paronychia.) 
Pancreas,  cysts  of,  607 

injuries  of,  607 
Papilloma,  100 

of  bladder,  675 
Paqiielin's  cautery,  143 
Paracentesis  abdominis,  576 
of  pericardium,  220 


Paracentesis  thoracis,  545 
Paralysis  in  aneurism,  267 

in  cranial  fracture,  359 

in  spinal  fractures,  3i'3 
tuberculosis,  45:> 

muscular,  deformities  from,  172 

of  bladder,  674 

s[)aslic,  deformity  from,  172 
Paraphimosis,  719 
Parietal  abscess,  578 
Paronychia,  167.     (See  aho  Felon.) 
Patches,  mucous,  77 
Patella,  dislocations  of,  511 

fractures  of,  431 

hooks,  434 

wiring  of,  435 
Pedicle,  management  of,  in  ovariotomy, 
611 

in  abdominal  operations,  572 
Pelvic  abscess,  577 

bones,  fractures  of,  377 
Pelvis,  fractures  of,  intra-rectal  pressure 
in, 380 
laceration  of  urethra  in,  378 
Penile  fistula.     (.See  Urethra,  fistulte  of.) 
Penis,  amputation  of.      (.See  Penis,  ex- 
cision of.) 

carcinoma  of,  722 

chancre  of,  721 

chancroid  of,  721 

congenital  abnormalities  of,  718 

fracture  or  rupture  of,  723 

herpes  of,  721 

inflammation  of,  720 

injuries  of,  72:! 

strings  tied  about,  720 

tumors  of,  722 

webbed,  718 
Perforating  ulcer  of  intestines,  585 
Perforation    of    palate.        (See    Palate, 
cleft.) 

of  vermiform  appendix,  595 
Pericardicentesis,  220 
Pericardium,  aspiration  of,  220 

incision  of,  220 

wounds  of,  219 
Perineal  abscess.     (.See  Abscess,  ischio- 
rectal ) 
Perineorrhaphy,  726 
Perinephritic  abscess,  659 
Perinephritis,  659 
Perineum,  laceration  of,  725 
Periosteum,  incision  of,  in  ostitis,  307 

inflammation  of,  302 
Periostitis,  302 

acute  infective,  302 

circumscribed,  303 

sj'mptoms  of,  303 

syphilitic,  303 

treatment  of,  303 

incisions  in,  303 
Perirectal  abscess,  642 
Perirenal  abscess,  659 
Peritoneum,  purulent  eft'usion  in,  578 

toilet  of,  572 


INDEX. 


791 


Peritonitis    after   abdominal   operations, 
575 
circumscribed,  576 
diffused  or  general,  577 
purgative  treatment  of,  575 
traumatic,  575 
Peritypblitis,  594 
Permanent  stricture.      [See  Stricture  of 

urethra,  organic.) 
Pernio,  165 
Pervious  urachus,  670 
Pes  calcaneus,  739 
equinus,  738 
planus,  739 
valgus,  738 
varus,  737 
Phagedena  of  vulva,  725 

siouffhing,  63 
Phalanges,  fractures  of,  of  fingers,  445 
of  lingers,  amputation  of,  754 
of  hand,  dislocations  of,  503 
of  toes,  amputation  of,  761 
dislocations  of,  512 
fractures  of,  445 
Pharyngotomy,  566 
Pharynx,  adenoid  vegetations  of,  531 
Phirao.sis,  718 

firceps,  719 
Phlebectasis.     (.%eVarix.) 
Phlebitis,  242 
septic,  243 
thrombosis  in,  245 
treatment  of,  243 
Phleboliths,  245 
Phlebotomy,  144 
Phlegmonous  abscess,  53 

erysipelas,  64 
Phosphorus  necrosis,  558 
Piles.     {See  Hemorrhoids.) 

oedematous,  642 
Pirogoff's  amputation,  759 
Plaster-of-Paris  dressings,  344 
jacket,  application  of,  457 
shears,  345 
splints,  341 
Plastic  operations,  147 
surgery.  146 

displacement  of  flaps  in,  147 
interpolation  of  flap*  in,  148 
methods  used  in,  147 
retrenchment  of  flaps  in,  148 
sloughing  of  flaps  in,  150 
transplanting  of  flaps  in,  148 
Plates,  Sen n's  decalcified  anastomosis, 602 
Pleura,  aspiration  of,  545 
drainage  of,  546 
effusion  into,  545 
irrigation  of,  546 
wounds  of,  543 
Pleurosthotonos  in  tetanus,  210 
Pliers,  bone-cutting,  516 

Butcher's  excision,  618 
Plugging  of  nares,  527 
Pneumectomy,  547 
Pneumotomy,  547 


Pneumouria,  683 

Pointing  of  abscesses,  53 

Poisoned  wounds,  120 

Polyps,  nasal,  529 

Polypus,  529 

Po.sterior  tibial  artery.     [See  Artery.) 

Posthitis,  720 

Potain's  aspirator,  144 

Pott's  disease,  451 

fracture.     {See  Fibula,  fractures  of.) 
Poultices,  antiseptic,  142 

flaxseed,  142 
Powder  marks,  treatment  of,  125 
Prepuce,  slitting  of,  718 
Priapism  in  spinal  fracture,  354 
in  spinal  inflammation,  201 
in  vesical  calculus,  678 
Probe,  jSTelaton,  124 
Probes,  127 
Proctectomv,  653 
Proctitis,  633 
Proctotomy,  651 
Productive  inflammation,  39 
Prolapse   of   anus.      (.See  Eectum,  pro- 
lapse of.) 
of  rectum,  635 

operations  for,  636 
Protective,  141 
Provisional  callus,  335 
Pruritus  of  anus,  633 
Pseudarthrosis,  3i7 
Psoas  abscess,  453 
Ptomaines,  65 
Pubic  bone,  fracture  of,  378 
Pubis,  aspiration  of  bladder  above,  683 

dislocation  of  femur  upon,  509 
Pulmonary  abscess,  547 

gangrene,  547 
Pulsation  in  arterial  varix,  301 
Pulse  in  aneurism,  268 
Puncture,  of  bladder,  683 

of  intestine,  572 
Purgative  treatment  of  peritonitis,  575 
Purulent  catarrh,  39 
effusion,  39,  51 
infiltration,  39,  51 
Pus,  calcification  of,  52 
caseation  of,  52 
composition  of,  50 
corpuscles,  51 
encapsulation  of,  52 
formation  of,  50 
j  tests  for,  51 

I  varieties  of,  51 

'  Pustule,  malignant,  122 
!  Pyarthrosis.       {See   Arthritis,    suppura- 
I      tive.) 
Pyemia,  65 

in  necrosis  of  bones,  310 
Pylorectomy,  583 
Pylorus,  divulsion  of,  584 
I  excision  of,  583 

•'  stricture  of,  584 

'  Pyo-nephrosis,  658 
\  Pyosalpinx,  612 


792 


INDEX. 


Q 


UILT  suture,  fiOO 
Quinsy,  5(>2 


RABID  animal.',  bites  of.     [See  Hydro- 
jihobia.) 
Rabies.     (See  Hydrophobia.) 
Kacemose  »neurism.     [See  Aneurism  by 

anastomosis  ) 
Kachitis  84 

adultorum.     (See  Osteomalacia.) 
Radial  artery.     [See  Artery.) 
Radical  treatment  of  hydmcele,  Tl'J 
Radius,  dislocations  of,  49!',  501 

fractures  of,  403,  406 
Ranula,  556 
Rarefying  ostitis,  o04 
Reaniputaiions,  T4o 
Rectal  speculum,  MX 
Recto-urethral  fistule.  fi4(i 

-vagiral  fistule,  7-7 

-vesical  fistule,  G4f) 
Rectum,  abscess  of,  642 

carcinoma  of,  652 

dilatation  of,  6o4 

diseases  of,  632 

excision  of,  653 

foreign  bodies  in,  fi3i 

hemorrhoids  of,  637 

impaction  of  feces  in,  634 

imperforate,  632 

operation  for,  632 

inflammation  of,  633 

malformations  of,  632 

prolapse  of,  635 

operations  for,  636 

stricture  of,  649 

cololomy  in,  652 
treatment  of,  651 

tumors  of,  652 

ulceration  of,  648 
Reduction  of  dislocations,  483 

of  prolapsed  rectum,  636 
Redundancy  of  scrotum,  710 
Reef  knot,  137 

Reeve's  universal  talipes  shoe,  737 
Refracture  for  vicious  union,  3-50 
Renal  calculi,  661 

colic,  662 

fi>tuhv,  663 
Reproducti\e  organs,  diseases  and  inju- 
ries of,  710 
Resection.     [See  Excision.) 

of  bunes,  in  ununited  fracture,  349 

of  intestine,  599 

anastomosis  after,  603 
Residual  abscess,  52 
Resolution  of  inflammatii  n,  45 
Respiration,    Cheyne-Slokes,    in     brain 

injury,  190 
Results  of  inflammation,  45 
Retained  menses,  727 
Retention  of  urine,  681 

in  spinal  fracture,  354 
in  stricture,  701 


Retractor,  for  amputations,  745 

Retro-pharyngeal  abscess,  563 

Reunion  of  nerves,  205 

Revulsion.     (See  Counter-irritation. 

Rhabdo-myoma,  95 

Rhinopla.^ly,  533 

Ribs,  dislocations  of,  489 

excision  of,  in  empyema,  54(5 

fracture  of,  ;)72 

symptoms  of,  374 
treatment  of,  375 
Rice-like  bodies,  176 
Rickets,  84 

Risus  sardonicus.     (See  Tetanus.) 
Rizzioli's  osteoclast,  351 
Roberts's  aseptic  trephine,  362 

operation  for  recial  prolapse,  636 

pericardial  trocar,  220 

segment  trephine,  363 
Rolando,  fissure  of,  189 
Rongeur  forceps,  .362 
Rotary  lateral  curvature  of  spine,  731 
Round  back,  731 

shoulders,  732 
Rubber  rings  for  intestinal  anastomosis, 

602 
Run-around.     (See  Onychia.) 
Rupia,  syphilitic,  78.     (See  also  Syphi- 
litic eruptions.) 
Rupture  of  bladder,  680 

of  intestine>,  585 

of  muscles,  169 

of  cesof)ha<;us,  .564 

of  penis,  723 

of  perineum,  725 

of  quadriceps  tendon,  435 

of  stomach,  579 

of  tendons,  169 

of  urethra,  706 


SACCULATED  arterio-venous  fistule, 
258 
Sac  of  hernia,  614 

contents  of,  614 
Sacro-iliac  articulation,  separation  of,  377 
Sacrum,  fracture  of,  378 
Saliva,  tests  for,  563 
Salivary  fistule,  563 
Salpingectomy,  613 
Salpingitis,  612 

Sanitary  measures  in  inflammation,  49 
Sapnemia,  65 
Sarcoma,  102 

alveolar,  104 

giant  cell,  105 

melanotic,  105 

myeloid,  105 

round-celled,  103 

spindle-celied,  104 
Sardcmic  grin  of  tetanus,  211 
Saw,  Adams's,  517 

aseptic  amputation,  745 

Butcher's  excision,  518 

chain,  517 


INDEX. 


im 


Sayre's  clavicle  apparatus,  384 

extension  apparatus,  457 
Scalds,  161 
Scalpel,  126 
Scalp  wounds,  191 
Scapula,  dislocations  of,  492 

fractures  of,  385 
Scars.      {See  Cicatrix.) 
Schede's  method  of  healing   by  blood- 
clot,  318 
Schizomycetes,  37 
Schneiderian  membrane.     (See  Catarrh, 

nasal.) 
Schirrus,  107 

Scleroderma      {See  Elephantiasis.) 
Screw,  Stromeyer's,  472 
Scrotum,  710 

elephantiasis  of,  710 

epithelioma  of,  710 

lymph,  710 

redundancy  of,  710 

split,  710 

varix  of,  710 
Scoliosis,  731 
Scrofulides,  72 
Scrofula,  71.     {See  also  Tuberculosis.) 

of  joints.  {See  Arthritis,  tubercular.) 
Scrofulous  affections.  {See  Tuberculosis.) 
Searcher  for  vesical  calculi.    {See  Sound, 

vesical.) 
Secondary  berhorrhape,  tieatment  of,  237 
Second  intention,  union  by.  {See  Union, 

secondary.) 
Section  of  abdomen,  572 

of  arteries.      {See  Artery  ;   arteriot- 
omy.) 

of  bone  in  amputations.     {See  Am- 
putations.) 
in  excisions,  517 

of  nerves  in  tetanus,  210 

of  tendons.     {See  Tenotomy.) 

of  veins  in  varicocele.     (See  Vari- 
cocele.) 
in  varix.     {See  Varix.) 
Semi-lunar  cartilages,  dislocation  of,  513 
Senile  gangrene,  61 

Senn's  decalcified  bone  plates  for  anas- 
tomosis, 602 

hydrogen  test,  571 
Sensory  neuritis,  204 
Septic  intoxication,  65 

wounds,  119 
Septicaemia,  65 

causes  of,  67 

diagnosis  of,  68 

from  venous  wounds,  240 

pathology  of,  66 

symptoms  of,  68 

treatment  of,  69 
Septum,  nasal,  deformities  of,  531 
Sequestrotomy,  311 
Sequestrum,  308 
Serous  inflammation,  38 
Serum,  transudate  of,  41 
Seton, in  ranula,  557 


Setons,  143 

Setting  of  fractures,  336,  337 

Sexual  organs,  diseases  and  injuries  of, 

710 
Shock,  114 

treatment  of,  115 
Shortening,  Allis's  test  for,  507 
Shot,  extraction  of,  125 
Shoulder-joint,  amputation  through,  750 
dislocations  of,  493 
excision  of,  519 
injuries  of,  diagnosis  of,  389 
Signorini's  tourniquet,  277 
Silver-fork  fracture.     {See  Kadius,  frac- 
tures of.) 
Sims's  vaginal  speculum,  728 
Sinus,  55 

of  chest-wall,  547 
Skin-grafting  for  ulceration,  57 

method  of,  57 
Skin-grafts,  57 
Skull,  fractures  of,  856 
Sloughing  phagedena,  63 

ulcer,  57 
Smith's  wire  splint,  429 
Snake  bites,  121 
Soft  cancer.   {See  Carcinoma,  medullary.) 

chancre.     {See  Chancroid.) 
Softening  of  bones.     (>S'ee  OsteomalHcia.) 
Soluble  glass.     {See  Sodium  silicate.) 
Solvent  treatment  of  calculus,  679 
Soot  cancer.     {See  Scrotum,  cancer  of.) 
Sound,  vesical,  678 
Sounding  the  bladder,  678 
Sounding-board,  679 
Spanish  windlass.     {See  Tourniquet.) 
Spasm,  muscular,  in  stumps,  749 
of  muscles,  in  fractures,  331 
of  cesophagus,  567 
of  sphincter  ani,  in  fissure,  647 
tetanic,  210 
Spastic  paralysis,  deformity  from,  172 
Specifics  in  inflammation,  49 
Speculum,  rectal,  648 

vaginal,  728 
Spermatic  veins,  excision  of,  715 
ligation  of,  714 
varix  of,  714 
Spermatorrhoea,  717 
Sphacelation.     {See  Gangrene.) 
Sphacelus.     {See  Slough  ;  gangrene.) 
Sphincter  ani,  division  of,  648 

relaxation    of,   in  hemorrhoids, 

638 
spasm  of,  in  fissure,  647 
stretching  of,  648 
Spina  bifida,  198 

Spinal   accessory  nerve,  stretching    and 
section  of,  in  torticollis,  730 
cord,  concussion  of,  203 
contusion  of,  203 
inflammation  of,  22 

in  meningitis,  200 
laceration  of,  203 
sclerosis  of,  in  myelitis,  200 


7it4 


INDEX, 


Spinal  cord,  wounds  of,  20o 

c;ir\alure«,  7^50 

meningitis,  200 

meningocele,  1 '.)'.» 
Spine,  angular  curvature  of,  4o-' 

ankylosis  of,  4  jo 

antero-posterior  curvature  of,  4-54 

bifid,  1'.I8 

curvatures  of,  7^0 
lateral,  7'>1 

r  itatory,  7:51 
treatment  nf,  7'-iii 

apparatus  in,  7o-> 

fracture  of,  prognosis,  o5o 

fracture  of,  852 

retention  of  urine  in,  854 
treatment  of,  -ioo 
trephining  in.  85'1 

Pott's  disease  of,  451 

trephining  of,  in  «poidylitis,  450 

tuberculosis  of,  451 
Splay-foot,  780.   (Sef.  a/.soTali[)es  %-algas.) 
Spleen,  cysts  of,  607 

excision  of,  ti07 

injuries  of,  007 
Splenectomy,  fi07 
Splenolomy,  007  • 

Splint,  bedsores  from,  848 

Bond's,  412 

gypsum,  841 

in  fractures,  840 

interdental,  8(37 

Levis's,  for  fracluri  of  radius,  411 

moulded,  841 

plaster-of-Paris,  841 

Smith's  wire,  420 

Siromeyer's,  for  ankylosis,  471 

Thomas's  hip,  405 
Splinters  of  bone.     (.S'ee  S  jquestrura.) 
Spondylitis,  451 
Sprain- fracture,  825 
Sprains  of  joints,  474 
Spring   apparatus  for  spinal  curvature, 
788 

clamps  for  intestinal  operations,  599 
Square,  Broca's,  18S 
Stab  wounds  of  abdomen,  571 
Staff,  lithotomy,  688 
Staffordshire  knot,  012 
Staphylojoccus  pyogenes  albus,  50 

aureus,  50 
Staphylorrhaphy.  554 
Stf-atoma.     (See  Tumors,  fattv.) 
Sterilization,  185 

of  instruments,  128 
Sterno-mastoid    muscle,   section    of,    in 

torticollis,  730 
Sternum,  dislocations  of,  491 

fractures  of,  371 

trephining   of,   for   mediastinal    ab- 
scess, 547 
Sthenic  fever,  44 
Stimulants  in  inflammation,  47 
Sting,    of    insects.     (Sse   "Wounds,    poi- 
soned.) 


.Stomach,  diseases  and  inj  tries  of,  578 
exploration  of,  578 
foreign  bodies  in,  570 
lavage  of,  570 
operations  upon,  570 
pump,  509 

introduction  of,  509 
rupture  of,  570 
stricture  of  orifices  of,  584 
suturing  of,  582 
tumors  of,  578,  588 
washing  out  of,  570 

before  operations,  579 
wounds  of,  570 
Stomatitis,  550 
Stoae  in  the  bladder.  070 

in  the  kidney,  001 
Strangulated  hernia.  020 
Strangulation  of  intestines.  580 
Strangury,  in  gonorrluea,  OOS 
Strapping  of  testicle,  716 
Streptococcus  pyogenes.  50 
Stretching  of  nerves.  20S 
in  tetanus,  212 
of  sphincter  ani,  048 
Stricture  of  gastric  orifices,  584 
of  intestine,  589 
of  oesophagus,  567 
of  pylorus,  584 
of  rectum,  640 
of  urethra,  700 
causes  of,  701 
dilatation  of,  702 
continuous.  708 
forcible,  704 
immediate,  704 
intermittent,  702 
rapid,  704 
exploration  of,  701 
organic  or  true,  700 
pathology  of,  701 
symptoms  anl  diagno  sis  of, 
~  701 

treatment  of,  702 
permanent.       {See   Stricture    of 
urethra,  organic.) 
Strome5'er's  ankylosis  splint,  471 

forceps,  491 
Struma      (See  Bronchocele.) 
Stumps,  ampulatioa,  diseases  and  inju- 
ries of,  749 
drainage  of,  747 
dressing  of,  747 
conical.  749 
Styptics  in  hemorrhage,  280 
Subclavian  artery.     {See  Artery.) 
Subclavicular  dislocation  of  humerus,  495 
Subcoracoid  dislo:;ation  of  humerus,    495 
Subcutaneous  hemorrhage,  221 
Subglenoid  dislocation  of  humerus,  493 
Subspinous  dislocation  of  huuier.is,    495 
Sulcus  of  PiOlando,  186 
Sunburn,  161 

Supination  in  fracture  of  forearm,  404 
Suppression  of  urine,  682 


INDEX. 


795 


Suppuration,  39,  50     {See  also  Abscess  ; 
pus;  inflammation.) 

acute,  39 

diffused,  52 

microorganisms  of,  50 
Suppurative  fever.     {See  Pyemia.) 

inflammation,  39 

neptiritis,  658 
Surgeon's  knot,  138 
Surgery  abdominal,  572 

orthopedic,  729 

plastic,  146 
Surgical  fever.     {See  Pyemia.) 
Suspension  apparatus,  457 

chair,  459 

in  spinal  inflammation,  202 
Suture,  buried,  140 

contin  lous,  137 

continuous,  of  intestine,  600 

cranial,  separation  of,  in  fractur^„3^7 

harelip,  137 

interrupted,  137 

Lembert's,  586 

of  heart,  220 

of  intestinal  wound-;,  586 

of  nerves,  206 

of  pericardium,  220 

of  veins,  240 

pin,  137 

quilt,  600 

removal  of,  138 

tongue  and  groove,  147 

twisted,  137 
Sutures,  136 

Suturing  of  stomach,  582 
Swelling,  inflammatory,  43 

in  fractures,  331 

(edematous,  43 

white.     {See  Arthritis,  tubercular.) 
Syme's  amputatioa,  757 
Symphysis  pubis,  absence  of  in  exstrophy, 
669 

aspiration  above.     {See  Bladder,  as- 
piration of.) 

diastasis  at,  378 
Symptomatic  fever,  44 
Synostosi-^,  470 

Synovial  membrane,  inflammation  of,  447 
Synovitis,  447 

purulent,  448 

septic,  448  • 
Syphilides.  77 
Syphilis,  74 

alopecia  in,  77 

arterial  changes  in,  78 

arthritis  in,  467 

caries  of  bone  in,  313 

causes  of,  74 

clinical  history  of,  75 

congenital,  79 

definition  of,  74 

diagnosis  of,  79 

fibroid  degenerations  in,  78 

gummy  deposits  in,  78 

hereditary,  78 


Syphilis,  hereditary,  treatment  of,  82 

heredity  of,  74 

incubation  stao;e  of  75 

inoculation  of,  74 

iritis  in,  77 

marriage  during,  75 

mucous  patches  in,  77 

of  tongue,  559 

of  vulva,  725 

primary'  stage  of,  75 

quarternary  stage  of,  78 

secondary  stage  of,  77 

symptoms  of,  75 

synovitis  in.     {See  Synovitis. ) 

teeth  in,  78 

tertiar\'  stage  of,  77 

treatment  of,  79 
Syphilitic  alopecia,  77 

arthritis,  467 

bubo,  76 

chancre,  75 

iritis,  77 

periostitis,  303 
Syphiloderms,  77 
Syringe,  Tait's,  574 

urethral,  700 


TAIT'S  cholelithotomy  forceps,  606 
L  ovariotomy  trocar,  611 

syringe,  574 
lalipes,  735 

calcaneo-valgus,  738 

calcaneus,  739 

equino-valgus,  738 

equino-varus,  737 

equinus,  738 

plano-varus,  738 

planus,  739 

treatment  of,  operative,  737 

universal  shoe  for,  737 

varus,  737 
Tampon,  for  plugging  nares,  528 
Tapping,  144 

of  abdomen,  576 

of  hydri)cele,  712 

of  hydrocephalus,  183 

of  joints,  515 

of  kidney,  665 

of  ovarian  cysts,  610 

of  pericardium,  220 
Tarsal  bones,  dislocation  of,  512 

excision  of,  in  club-foot,  737 
fracture  of,  444 
Tarsus,  dislocations  of,  512 

fractures  of,  444 
Taxis,  in  hernia,  620 
Taylor's  osteoclast,  351 
Teale's  method  of  amputation,  748 
Teeth,  abscess  of,  557 

in  syphilis,  78 
Temperature  in  inflammation,  43 

in  tetanus,  210 
Temporo-maxillary    joint,  excision    of, 
519 


796 


INDEX. 


Tenaculum,  127 

Tendon    of   Achilles,    tenotomy    of,    in 
fracture,  4o() 
in  leg  fracture,  441 

quadriceps,  rupture  of,  485 
Tendons,  contractii'U    of.      [See   Orlho- 
pedic  surgery.) 

dislocation  of,  170 

division  of,  17:^ 

in  fractures,  174 

inflammation  of,  170 

rupture  of,  IGU 

suture  of,  140 

suturing  of,  IfiO 

wounds  of,  169 
Tenosuture,  IfJO 
Tenosynovitis,  170 

deformity  from,  171 
Tenotome,  173 
Tenotomy,  173 

correction  of  deformity  after,  174 

for  muscular  siiasm,  174 

in  club-foot,  7->6 

in  luxation  of  muscles  and  tendons, 
170 

of  sterno-mastoid,  in  torticollis,  7;>0 
Terminations  of  inflammation,  45 
Test  for  pus,  51 

saliva,  563 

Senn's  hydrogen,  571 
Testicle,  abnormalities  of,  715 

excision  of,  717 

inflammation  of,  715 

injuries  of,  717 

malposition  of,  715,720 

strapping  of,  716 

tuberculosis  of,  715 

undescended,  715 
Tetanus,  209 

diagnosis  of,  211 

from  ligation  «>f  umbilical  cord,  210 

hyperpyrexia  in.  210 

opisthotonos  in,  210 

pr  'gnosis  of,  211 

sardonic  grin  of,  211 

symptoms  of,  210 

treatment  of,  211 
Theca,  inflammalion  of,  170,  179 
Thecal  cvst,  176 
Thecitis,"'l70 

crepitation  in,  179 
Thenno-cauterj',  143 
Thigh,  amputation  of,  757 

bone.     (See  Fetnur.) 

dislocations  (»f,  505 
Thomas's  hip  splint,  465 
Thoracentesis,  545 
Thorax.     (See  Chest.) 

diseases  of,  542 
Thornton's  T-shaped  f.jrceps,  611 
Thrombosis  in  phlebitis,  245 
Thrombus,  67 

venous,  66 
Thrill  in  aneurism,  268 
Thumb,  amputation  of,  753 


Thumb,  dislocatitms  of,  504 
Thyroid  body  or  gland,  diseases  of,  548 
excision  of,  550 
hypertrophy  of,  549 
tumors  of,  549 

dislocations  of  the  femur,  50y 
Thyrotomy,  537 
Tibia,  deformities  of,  742 

dislocations  of,  51 1 

fractures  of,  436 
Tip-tilted  nose,  531 
Tissues  in  inflammation,  42 
Toe-nail,  ingrowing,  167 
Toilet  of  peritoneum,  573 
Tongue,  abscess  of,  559 

biting  of,  in  tetanus,  210 

diseases  of,  559 

epithelioma  of,  560 

tracheotomy  in,  561 
cesophagotomy  in,  561 

excision  of,  500 

foreign  bodies  in,  560 

gumma  of,  560 

ichthyosis  of,  560 

incision  of,  559 

inflammation  of,  559 

leucoma  of,  560 

psoriasis  of,  560 

syphilis  of,  559 

-tie,  559 

tumors  of,  560 
Tonics  in  inflammation,  48 
Tonsillitis,  562 
Tonsillotome,  562 
Tonsillotomy,  562 
Tonsils,  abscess  of,  562 

bleeding  from,  after  excision,  562 

diseases  of,  562 

excision  of,  562 

hypertrophy  of,  562 

tuberculosis  of,  562 
Torsion  of  arteries,  234 
Torticollis,  729 
Tourniquet,  Esmarch's,  745 

Signorini's,  277 
Trachea  dilator,  539 

foreign  bodies  in,  534 

fractures  of,  534 

tube,  539,  541 

tumors  of,  536 
Tracheotomy,  538 

in  fracture  of  larynx,  370 

in  lingual  cancer,  561 

in  tetanus,  212 

in  wounds  of  neck,  547 
Transfusion,  228 

direct,  228 

indirect,  228 

of  milk,  229 

of  saline  solutions,  229 
Transplatitation  of  nerve,  206 
Transportation  of  the  injured,  337 
Transudate  of  serum,  41 
Traumatic  aneurism,  255 

inflammation,  34 


INDEX. 


797 


Traumatic  peritonitis,  575 
Trephine,  362 

Eoberts's  aseptic,  362 
segmented,  363 
Trephining,  bone-grafting  after,  364 

for  bone  abscess,  317 

for  brain  lesions,  189 

for  brain  tumors,  198 

for  compression  of  brain,  197 

for  epilepsy,  863 

hemorrhage  during,  364 

in  brain  inflammation,  186 

in  cranial  fracture,  360 

in  ostitis,  307 

in  spinal  fracture,  356 

incision  of  dura  mater  in,  364 

metallic  plate  after,  364 

of  spine  in  spondylitis,  459 

of  sternum  for  mediastinal  abscess, 
547 

of  vertebrae  in  spinal  inflammation, 
203 

operation  of,  362 
Trismus,  209 
Trocar,  aspiration,  145 

for  tapping  hydrocele,  712 

pericardial  aspirating,  221 

Tait's  ovariotomy,  611 
Trusses  for  hernia,  617 

application  of,  618 
Tube,  stomach,  569 

introduction  of,  569 

tracheal,  539,  541 

tracheotom}',  539 
Tubes,  drainage,  for  abdomen,  573 
glass,  573 

Fallopian,  diseases  of,  612 
Tubercle  of  joints,  450 

painful  subcutaneous,  96 
Tubercular  abscess,  53 

arthritis,  450 

ulcers,  treatment  of,  59 
Tuberculosis,  bacillus  of,  71 

causes  of,  72 

definition  of,  71 

general  consideration  of,  71 

n)iliary,  71 

of  bladder,  674 

of  cervical  glands,  548 

of  glands,  250 

of  hip-joint,  461 

of  kidney,  660 

of  larynx,  536 

of  lip.     [See  Lupus.) 

of  mammar}'^  glands,  764 

of  sacro-iliae  articulation,  460 

of  testicle,  716 

of  tonsils,  562 

of  vertebral  articulations,  451 

of  vulva,  725 

pathology  of,  71 

symptoms  of,  72 

treatment  of,  73 
Tuberculous  lymphadenitis,  250 

ulceration  of  bone,  313 


Tufnell's  arterial  truss,  278 
Tumors,  86 

adenomatous,  101 

bony,  93 

bursal,  178 

cancerous,  106 

carcinomatous,  105 

cartilaginous,  91 

cauliflower,  100 

causes  of,  86 

causes  of  death  from,  89 

circumscribed,  87 

classification  of,  88 

clinical  history  of,  89 

colloid,  108 

changes  in,  108 

congenital,  of  men'nges,  182 

cystic,  110 

varieties  of,  111 

definition  of,  86 

diffuse,  87 

encephaluid,  108 

epitheliomatous,  106,  108 

fatty,  90 

fibrous,  90 

glandular,  10 1 

leio-myomatous,  95 

lymphomatous,  94 

malignant,  87 

metastatic,  87 

mucous,  93 

muscular,  95 

myomatous,  95 

nasal,  529 

nervous,  96 

non-malignant,  87 

of  bladder,  675 

of  bone,  320 

of  brain,  198 

of  intestine,  591 

of  jaw,  557 

of  joints,  448 

of  kidney,  663 

of  larynx,  536 

of  liver,  604 

of  mammary  glands,  766 

of  mediastinum,  547 

of  mouth,  556 

of  oesophagus,  566 

of  omentum,  591 

of  ovary,  608 

of  penis,  722 

of  stomach,  578,  583 

of  stumps,  749 

of  synovial  membranes  of  joint-,  448 

of  testicle,  717 

of  trachea,  536 

of  tongue,  560 

of  urethra,  706 

of  vagina,  728 

of  vulva,  725 

papillomatous,  100 

pathology  of,  86 

recurrent  fibroid,  105 

rhabdo-myomatous,  95 


798 


INDEX, 


Tumors,  sarcomatoiie,  lO'i 
alveolHF,  104 
giant-cell,  105 
melanotic,  105 
mjeloid,  105 
round  celled.  103 
spindle-celled,  104 
scirrhus,  107 
secondary,  87 
treatment  of,  89 
vascular,  !tG 
Tunica  vaginalis,  hematocele  of,  713 
hydrocele  of,  711 
excision  of,  713 
incision  and  dritinage  of,  713 
loose  bodies  in,  711 
tapping  of,  711i 
Turned-up  nose,  531 
Typhlitis,  594 
Typhoid  condition,  44 

fever,  rupture  or  perforation  of  in- 
testines in,  585 


ULCER,  atheromatous,  262 
callous,  57 

chronic,  57 

closed,  58 

duodena],  from  burns,  16o 

fungous,  57 

indolent,  57 

mucous,  59 

rupial,  78 

syphilitic,  78 

treatment  of,  57 

skin-grafting  in,  57 

varicose,  57 
Ulceration,  39,  45,  55 

gangrenous,  63 

of  stumps,  749 

of  vulva,  725 

tuberculous,  of  bone,  313 
Ulcers,  definition  of,  56 

general  consideration  of,  56 

of    vulva,    destructive    and    hyper- 
trophic, 725 

sloughing,  57 

treatmeni  of,  plastic  operations  in,  58 
pressure  in,  59 

tubercular,  treatment  of,  59 

varieties  of,  56 
Ulna,  dislocations  of,  499,  502 

fracture  of,  405 
Ulnar  artery.     (.S'ee  Artery.) 
Umbilical  hernia,  630 
Union  by  first  intention,  117 

by  secondary  intention,  117 

of  apposed  granulating  surfaces,  164 

of  divided  nerves,  205 

of  fractures,  deformed  or  vicious,  3.50 
delayed,  347 
Ununited  fractures,  347 
Urachus,  calculi  in,  571,  670 

patulous,  571 

pervious,  670 


Uranoplasty,  555 
Ureters,  calculi  in,  705 

catheterization  of,  655,  668,  707 
compression  of,  655 
diseases  and  defects  of,  668 
Urethra,    Boutonnierc    operation    upon. 
[See  External  urethrotomy.) 
caruncle  of,  706 

catlieterizaticm  of,  in  female,  708 
dilatati<'n  of,  702 
in  female,  70!l 

incontinence  after,  709 
exploration  of,  701 
fistulre  of,  705 
foreign  bodies  in,  705 
hemorrhoids  of,  706 
inflammation  of,  698 
injuries  of,  706 

laceration  of,  in  pelvic  fiactures,  378 
normal  calibre  of,  702 
operations  upon,  707 
rupture  of,  706 
stricture  of,  700 

organic  or  true,  700 
tumors  of,  706 

fibro-vascular,  of  female,  706 
wounds  of,  706 
Urethral  fever,  704 
fistulje,  705 
forceps,  705 
injection  syringe,  700 
Urethritis,  698 

chronic  specific,  699 
gonorrhoeal,  698 
non-specific,  698 
simple,  698 
specific,  698 
Urethrocele,  698 

operati(in  for,  698 
Urethrotome,  708 
Urethrotomy,  external,  709 
in  stricture,  704 
internal,  708 

in  stricture,  704 
Urethro-vaginal  fisiula,  727 
Urinal  for  vesical  exstrojihy,  669 
Urine,  air  in,  683 
blood  in,  682 
chyle  in,  683 
incontinence  of,  682 

after  dilatation  of   female  ure- 
thra, 709 
in  spinal  inflammation.  201 
in  vesical  calculus,  678 
true,  682 
false,  682 
retention  of,  680 

in  fractures,  343 
in  spinal  fracture,  354 
in  spinal  inflammation,  201 
suppression  of,  682 
Uterus,  excision  of,  608 
injuries  of,  607 
tumors  of,  607 

fibro-myoraatous,  607 


INDEX. 


799 


VAGINA,    chancre  and  chancroid  of, 
727 
congenital  abnormalities  of,  726 
cystocele  of,  671 
fistulfe  of,  727 

repair  of,  728 
inflammation  of,  727 
Vaginal  hysterectom}-,  608 
Vaginitis,  727 

Valgus.     [See  Talipes  valgus.) 
Van  "Wagenen's  fracture  dressing,  344 
Varicocele,  714 
Varicose  aneurism,  256 
arteries,  300 
lymphatic  vessels,  251 
ulcer,  57 
veins,  244 

in  aneurism,. 267 
ligation  of,  246 
treatment  of,  245 
Varix,  244 

aneurismal,  256 
aneurismoid,  257 
arterial,  300 
of  scrotuip,  710 
of  spermatic  veins,  714 
of  stumps,  749 
of  vulva,  723 
Varus.     {See  Talipes  varus.) 
Vegetations.       (.See  "Warts  ;    papilloma; 

adenoma;  polypus.) 
Veins,  air  in,  241 

prevention  of,  241 
symptoms  of,  241 
treatment  of,  241 
coagulation  in.     (.See  Phlebitis.) 
concretions  in,  245 
diseases  of,  242 
hypertrophy  of,  244 
inflammation  of,  ^42 
ligation  of,  240 
occlusion  of,  in  aneurism,  267 
of  vulva,  varix  of,  723 
rupture  of,  subcutaneous,  239 
spermatic,  varix  of,  714 
suture  of,  240 
varicose,  in  aneurism,  267 
varicosity  of,  244 
wounds  of,  239 
Vein-stones.     (.See  Phlebolilhs.) 
Velpeau's  clavicle  bandage,  385 
Venesection,  144.     (.See  Bleeding  ;  blood- 
letting.) 
in  inflammation,  48 
Ventricles,     puncture     of,     in      hydro- 
cephalus, 183 
Verruca,  100,  153.     (.See  T\'arts.) 
Vermiform  appendix,  excision  of,  595 
foreign  bodies  in,  594 
inflammation  of,  594 
perforation  of,  595 
Vertebra,  dislocations  of,  487 
cervical,  487 
dorsal,  488 
fractures  of,  352 


Vertebrae,  fractures  of,  paralysis  in,  353 
pathology  ot,  353 
symptoms  of,  353 
trephining  of,  in  spinal   inflamma- 
tion, 20'3 
tuberculosis  of,  451 
diagnosis  of,  454 
symptoms  of,  451 
treatment  of,  456 
Vertical  extension  in  femoral  fractures, 

429 
Vesical  fistulae,  674 
Vesico-vaginal  fistula,  727 
Viscera.     (.See  Individual  organs.) 

abdominal.  (.See  Abdominal  organs.) 
Volvulus,  589 
Vomiting  in  hernia,  617 

in  spinal  fractures,  354 
Vulva,  abscess  of,  724 

adhesion  of  lips  of,  723 
chancre  of,  725 
chancroid  of,  725 
elephantiasis  of,  725 
epithelioma  of,  725 
hematoma  of,  724 
imperforate,  723 
inflammation  of,  724 

follicular,  724 
lupus  of,  725 
phagedena  of,  725 
syphilis  of,  725 
tuberculosis  of,  725 
tumors  of,  725 
ulcers  of,  725 
varix  of,  723 
■wounds  of,  725 
Vulvitis,  724 

Vulvo-vaginal  glands,  inflammation  of, 
724 


WAKDPvOP'S  method  of  ligation,  281 
Warts,  100, 153 
Washing  out  of  joints,  515 

of  stomach,  570 
Water-bed  in  fractures,  337 
Watson's  arterial  compressor,  276 
Weak  ankles,  739 
Webbed  fingers,  734 

penis,  718 
Wens.     (,S'ee  Cysts,  sebaceous.) 
Whalebone  bougies,  704 
White  swelling.     [See  Arthritis,  tuber- 
culous.) 
Wilson's  cyrtometer,  190 
Windlass,  Spanish.     {See  Tourniquet.) 
Windpipe.     (&e  Trachea;  larynx.) 
Wiring  of  patella,  435 
Wounds,  113 

arteno-venous,  256 

aseptic,  fever  in,  65 

definition  of,  113 

dissection,  122 

dressing  of,  141 

gunshot,  123 


800 


INDEX. 


"Wounds  of  abdomen,  571 
gunshiit,  5T1 
slab,  571 

of  arteries,  22*2,  252 

of  bladder,  r.80 

of  brain,  102 

of  cbest,  548 

of  sjall-birtdder,  <;()4 

of  heart,  2\'J 

of  intestines,  584 

of  joints,  474 

of  kidney,  6<)4 

of  liver,  <i03 

of  lung,  543 

of  lymphatics,  247,  252 

of  nerves,  205 

of  oesophagus,  504 

of  pancreas,  607 

of  pericardium,  219 
suture  of.  220 

of  pleura,  543 

of  scalp,  191 

of  spina!  cord,  203 

of  spleen,  007 

of  stomach,  579 

of  urethra,  700 

of  uterus,  607 


Wounds  of  vaurina,  728 

of  veins,  239 

of  vulva,  725 

poisoned,  120 

repair  of,  117 

sej)tic,  69 

treatment  of,  119 

shocl<  in,  113 

suture  of,  137,  147 

symptoms  of,  113 

treatment  of,  118 

constitutional,  118 

varieties  of,  113 
Wrist-joint,  amputation  through,  752 

dislocations  of,  502 

excision  of,  520 

fractures  near,  400 
Wry-neck,  729 


y-LIGAMENT.     (.See  Ligament,  ileo- 
1      femoral.) 

y  YGOMA,  fracture  of,  ^OO 


< 


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Being  the  medium  chosen  by  the  best  minds  of  the  profession  during  the  past  seventy 
years  for  the  presentation  of  their  ablest  papers,  The  American  JoitrxaIj  has  well 
earned  the  praise  accorded  it  by  an  unquestioned  authority — "from  this  file  alone,  were 
all  other  publications  of  the  press  for  the  last  fifty  years  destroyed,  it  would  be  possible  to 
reproduce  the  great  majority  of  the  real  contributions  of  the  world  to  medical  science 
during  that  period."  Original  Articles,  Reviews  and  Progress,  the  three  main  departments 
into  which  the  contents  of  The  Jourxal  are  divided,  will  be  found  to  possess  still  greater 
interest  than  in  the  past.  The  brightest  talent  on  both  sides  of  the  Atlantic  is  enlisted  in 
its  behalf  and  no  effort  will  be  spared  to  make  The  Journal  more  than  ever  worthy  of 
its  position  as  the  representative  of  the  highest  form  of  medical  thought. 

COM  M  UTATION^  ATE. 

Taken  together,  The  Journal  and  News  form  a  peculiarly  useful  combination, 
and  afford  their  readers  the  a.ssurance  that  nothing  of  value  in  the  progress  of  medical 
matters  shall  escape  attention.  To  lead  every  reader  to  prove  this  personally  the  com- 
mutation rate  has  been  placed  at  the  exceedingly  low  figure  of  $7.50. 

SPECIAL  OFFERS. 

The  Medical  News  Vlsiting  List  (regular  price,  $1.25,  see  next  page,)  or  The 
Year- Book  of_  Treatment  (regular  price,  $1.25,  see  page  17,)  will  be  furnished  to  advance- 
paying  subscribers  to  either  or  both  of  these  periodicals  for  75  cents  apiece  ;  or  Journal, 
News,  Visiting  List  and  Year- Book,  $8.50. 

Subscribers  can  obtain,  at  the  close  of  each  volume,  doth  covers  for  The  Journal  (one 
annucdly),  and  for  The  News  {one  annually),  free  by  mail,  by  remitting  Ten  Cents  for  The 
Journal  cover,  and  Fifteen  Cents  for  The  News  cover. 

J8@"The  safest  mode  of  remittance  is  by  bank  check  or  postal  money  order,  drawn  to 
the  order  of  the  undersigned  ;  where  these  are  not  accessible,  remittances  for  subscriptions 
may  be  sent  at  the  risk  of  the  publishers  by  forwarding  in  registered  letters.     Address, 

LEA  BROTHERS  &  CO.,  706  &  708  Sansom  Street,  Philadelphia. 


Lea  Brothers  &  Co.'s  Publications — Period.,  Manuals. 


THB  IIJEDICAZ  JS'^JEWS  VISITING  LIST  FOB  1890 

Has  been  revised  and  brought  thoroughly  up  to  date  in  every  respect.  It  con- 
tains 48  pages  of  test,  including  calendar  for  two  years;  obstetric  diagrams;  scheme 
of  dentition ;  tables  of  weights  and  measures  and  comparative  scales ;  instructions  for  ex- 
amining the  urine;  list  of  disinfectants;  table  of  eruptive  fevers ;  lists  of  new  remedies 
and  remedies  not  generally  used  ;  incompatibles,  poisons  and  antidotes ;  artificial  respira- 
tion ;  table  of  doses,  prepared  to  accord  with  the  last  revision  of  the  U.  S.  Pharmacopoeia  • 
an  extended  table  of  Diseases  and  their  remedies,  and  directions  for  ligation  of  ar- 
teries. _  176  pages  of  blanks  for  all  records  of  practice  and  erasable  tablet.  Handsomely 
bound  in  limp  Morocco,  with  pocket,  pencil,  rubber  and  catheter  scale. 

The  Medical  News  Visiting  List  for  1890  is  issued  in  three  styles,  as  heretofore: 
Weekly  (for  30  patients) ;  Monthly,  and  Perpetual.  Each  in  one  volume,  ^1.25.  Also 
furnished  with  Ready  Reference  Thumb-letter  Index  for  quick  use,  25  cents  extra.  For 
special  offers,  including  Visiting  List,  see  pages  1  and  2. 

This  list  is  all  that  could  be  desired.  It  con-  !  list  of  diseases  arranged  alphabetically,  giving 
tains  a  vast  amount  of  useful  information,  especi-  !  under  each  a  list  of  the  prominent  drugs  em- 
ally  for  emergencies,  and  gives  good  table  of  doses  \  ployed  in  the  treatment.  When  ordered,  a  Ready 
and  therapeutics.— O'mndiare  Practitioner.  ,  Reftsrence  Thumb-letter  Index  is  furnished.   This 

It  is  a  masterpiece.    Some  of  the  features  are  \  is  a  feature  peculiar  to  this  Visiting  List. Physi- 

peculiar  to  "The   Medical   News  Visiting  List,"  |  dan  ana  Surgeon,  December. 

notably  the  Therapeutic  Table,  prepared  from  Dr.  i      For  convenience  and  elegance  it  is  not  surpass- 

T.  Lauder  Brunton's  book,  which  contains  the  !  able. — Obs'itri'  Qazette  November. 


TJBLB  MEDICAL  NEWS  PHTSICIANS'  LEDGEB, 

Containing  400  pages  of  fine  linen  "  ledger  "  paper,  ruled  so  that  all  the  accounts  of  a 
large  practice  may  be  conveniently  kept  in  it,  either  by  single  or  double  entry,  for  a  long 
period.  Strongly  bound  in  leather,  with  cloth  sides,  and  with  a  patent  flexible  back, 
which  permits  it  to  lie  perfectly  flat  when  opened  at  any  place.  Price,  $5.00.  Also, 
a  small  special  lot  of  same  Ledger,  with  300  pages.     Price,  $4.00. 


SABTSSOBNE,  SENMY,  A,  M,,  M.  D.,  LL.  Z>., 

Lately  Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

A  Conspectus  of  the  Medical  Sciences ;  Containing  Handbooks  on  Anatomy, 
Physiology,  Chemistry,  Materia  Medica,  Practice  of  Medicine,  Surgery  and  Obstetrics. 
Second  edition,  thoroughly  revised  and  greatly  improved.  In  one  large  royal  12mo. 
volume  of  1028  pages,  with  477  illustrations.     Cloth,  $4.25 ;  leather,  $5.00. 


The  object  of  this  manual  is  to  afford  a  conven- 
ient work  of  reference  to  students  during  the  brief 
moments  at  their  command  while  in  attendance 
upon  medical  lectures.  It  is  a  favorable  sign  that 
it  has  been  found  necessary,  in  a  short  space  of 
time,  to  issue  a  new  and  carefully  revised  edition. 
The  illustrations  are  very  numerous  and  unusu- 
ally clear,  and  each  part  seems  to  have  received 
Its  due  share  of  attention.  We  can  conceive  such 
a  work  to  be  useful,  not  only  to  students,  but  to 
practitioners  as  well.    It  reflects  credit  upon  the 


industry  and  energy  of  its  able  editor. — Boston 

Medical  and  Surgical  Journal,  Sept.  3,  1874. 

We  can  say  with  the  strictest  truth  that  it  is  the 
best  work  of  the  kind  with  which  we  are  ac- 
quainted. It  embodies  in  a  condensed  form  all 
recent  contributions  to  practical  medicine,  and  is 
therefore  useful  to  every  ousy  practitioner  through- 
out our  country,  besides  being  admirably  adapted 
to  the  use  of  students  of  medicine.  The  book  is 
faithfully  and  ably  executed.— Charleston  Medical 
Journal,  April,  1875. 


NEILL,  JOSN,  M,  D.,   and  SMITS,  F,  G.,  M.  !>., 

Late  Surgeon  to  the  Penna.  Hospital.  Prof,  of  the  Institutes  of  Med.  in  the  Univ.  of  Penna. 

An  Analytical  Compendium  of  the  Various  Branches  of  Medical 
Science,  for  the  use  and  examination  of  Students.  A  new  edition,  revised  and  improved. 
In  one  large  royal  12mo.  volume  of  974  pages,  with  374  woodcuts.    Cloth,  $4 :  leather,  $4.75. 

LVDLOW,  J.L.,M.I),, 

Consulting  Physician  to  the  Philadelphia  Hospital,  etc. 

A  Manual  of  Examinations  upon  Anatomy,  Physiology,  Surgery,  Practice  of 
Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy  and  Therapeutics.    To  which 
is  added  a  Medical  Formulary.    Third  edition,  thoroughly  revised,  and  greatly  enlarged.   la 
one  12mo.  volume  of  816  pages,  with  370  illustrations.     Cloth,  $3.25 ;  leather,  $3.75. 

The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders  it  espe- 
cially suitable  for  the  office  examination  of  students,  and  for  those  preparing  for  graduation. 

SOBLYN,  BICHABD  D.,  M,  D,  .    .     ^  „  .      . 

A  Dictionary  of  the  Terms  Used  in  Medicine  and  the  CoUaterat 
Sciences.  Eevised,  with  numerous  additions,  by  Isaac  Hays,  M.  D.,  late  editor  of 
The  American  Journal  of  the  Medical  Sciences.  In  one  large  royal  12mo.  volume  of  520 
double-columned  pages.     Cloth,  $1.50 ;  leather,  $2.00. 

It  is  the  best  book  of  definitions  we  have,  and.ought  always  to  be  upon  the  student's  table.-Soui^er» 
Medical  and  Surgical  Journal.  ->^ja 


4  Lea  Brothers  &  Co.'s  Publications — Dictionaries. 

JUST    READY, 

THE 

DffTionAL  nieDieAL  Dk^tiohaky 

INCLUDING 

English,  French,  German,  Italian  and  Latin  Technical  Terms  used  in  Medicine  and 
the  Collateral  Sciences,  and  a  Series  of  Tables  of  Useful  Data. 

BY 

John  %  Billing^,  ]V[.D.,  LL.D.,  Ediq.  and  Harv.,  D.d.L.,  D^oi]. 

Member  of  the  National  Academy  of  Sciences,  Surgeon  V.  S.  A.,  etc. 

WITH  THE  COLLABORATION  OF 

Prof.  W.  O.  ATWATER.  JAMES  M.  FLINT,  M.  D.,  WASHINGTON  MATTHEWS,  M.D., 

FRANK  BAKER,  M.  D.,  J.  H.  KIDDER,  M.  D.,  C.  S.  MINOT,  M.D. 

8.  M.  BURNETT,  M.  D.,  WILLIAM  LEE,  M.D.,  H.  C.  YARROW,  M.  D., 

W.  T.  COUNCILMAN,  M.  D.,  R.  LORINI,  M.  D., 

In  two  very  handsome  royal  octavo  volumes  containing  1574  pages, 
with  two  colored  plates. 

Per  Volume— ClofJi,  $6;   Leather,  $7;   Half  Morocco,  Narhled  Edges,  $8.60.    For  Sale 
by  Sithseription  only.    Specimen  pages  on  application.    Address  the  JPublishera. 


The  publishers  have  great  pleasure  in  presenting  to  the  profession  a  new  practical 
working  dictionary  embracing  in  one  alphabet  all  current  terms  used  in  every  depart- 
ment of  medicine  in  the  five  great  languages  constituting  modern  medical  literature. 

For  the  vast  and  complex  labor  involved  in  such  an  undertaking  no  one  better  quali- 
fied than  Dr.  Billings  could  have  been  selected.  He  has  planned  tlie  work,  chosen  the 
most  accomplished  men  to  assist  him  in  special  departments,  and  personally  supervised 
and  combined  their  work  into  a  consistent  and  uniform  whole. 

Special  care  has  been  taken  to  render  the  definitions  clear,  sharp  and  concise. 
Pronunciation  has  been  indicated  by  a  simple  phonetic  spelling  and  by  accents  wherever 
necessary.  The  definitions  are  given  in  English,  with  synonyms  in  French,  German 
and  Italian  of  the  more  important  words  in  English  and  Latin. 

Regarded  as  a  dictionary,  therefore,  this  coming  standard  supplies  the  physician, 
surgeon  and  specialist  with  all  information  concerning  medical  words,  simple  and  com- 
pound, found  in  English,  giving  correct  spelling,  clear,  sharp  definitions  and  proper 
pronunciation,  and  furthermore  it  enables  him  to  consult  foreign  works  and  to  underetand 
the  large  and  increasing  number  of  foreign  words  used  in  medical  English.  It  is  especi- 
ally full  in  phrases  comprising  two,  three  or  more  words  used  in  special  senses  in  the 
various  departments  of  medicine. 

The  work  is,  however,  far  more  than  a  dictionary,  and  partakes  of  the  nature  of  an 
encyclopaedia,  as  it  gives  in  its  body  a  large  amount  of  valuable  therapeutical  and  chemi- 
cal information,  and  groups  in  its  tables,  in  a  condensed  and  convenient  form,  a  vast 
amount  of  important  data  which  will  be  consulted  daily  by  all  in  active  practice. 

The  completeness  of  the  work  is  made  evident  by  the  fact  that  it  defines  84,844 
separate  words  and  phrases. 

The  type  has  been  most  carefully  selected  for  boldness  and  clearness,  and  everj'thing 
has  been  done  to  secure  ease  and  rapidity  in  use. 


Its  scope  is  one  which  will  at  once  satisfy  the 
student  and  meet  all  the  requirements  of  the  med- 
Ical  practitioner.  Clear  and  comprehensive  defi- 
nitions of  words  should  form  the  prime  feature  of 
Bny  dictionary,  and  in  this  one  the  chief  aim 
seems  to  be  to  give  the  exact  signification  and  the 
different  meanings  of  terms  in  use  in  medicine 
and  the  collateral  sciences  in  Kinguage  as  terse  as 


three  modern  continental  languages  which  are 
richest  in  medical  literature.  To  add  to  its  use- 
fulness as  a  work  of  reference  some  valuable 
tables  are  given.  Another  feature  of  the  work  is 
the  accuracy  of  its  definitions,  all  of  which  have 
been  checked  by  comparison  with  manj[  other 
standard  works  in  the  different  languages  it  deals 
with.    Apart  from  the  boundless  stores  of  informa- 


is  compatible  with  lucidity.  The  utmost  brevity  j  tion  which  may  be  gained  by  the  study  of  a  good 
and  conciseness  have  been  kept  in  view.  The  work  dictionary,oneisenabledby  the  work  under  notice 
is  remarkable,  too,  for  its  fulness.  The  enumera-  to  read  intelligently  any  technical  treatise  in  any 
tions  and  subdivisions  under  each  word  heading  I  of  the  four  chief  modern  language.'.  There  can- 
are  strikingly  complete,  as  regards  alike  the  Eng  |  not  be  two  opinions  as  to  the  great  value  and  use- 
lish  tongue  and  the  languages  chiefly  employed  I  fulness  of  this  dictionary  as  a  book  of  ready  refer- 
by  ancient  and  modern  science.  It  is  impossible  j  ence  for  all  sorts  and  conditions  of  medical  men. 
to  do  justice  to  the  dictionary  by  any  casual  illus  So  far  as  we  have  been  able  to  see,  no  subject  has 
t  ration.  It  presents  to  the  English  reader  a  !  been  omitted,  and  in  respect  of  completeness  it  will 
t  horoughly  scientific  mode  of  acquiring  a  rich  {  be  found  distinctly  superior  to  anv  medical  lexicon 
vocabulary  and  offers  an  accurate  andreadv  means  I  yet  published.— TAe  London  Lancet,  April  5, 1890. 
of  reference  in  consulting  works  in  any  of  the  I 


Lea  Brothers  &  Co.'s  Publications — Anatomy.  5 

GHAT,  SENUY,  F,  B.  S., 

Lecturer  on  Anatomy  at  St.  George^s  Hospital,  London. 

Anatomy,  Descriptive  and  Surgical.  Edited  by  T.  Pickering  Pick, 
F.  R.  C,  S.,  Surgeon  to  and  Lecturer  on  Anatomy  at  St.  George's  Hospital,  London, 
Examiner  in  Anatomy,  Koyal  College  of  Surgeons  of  England.  A  new  American  from 
the  eleventh  enlarged  and  improved  London  edition,  thoroughly  revised  and  re-edited 
by  William  W.  Keen,  M.  D.,  Professor  of  Surgery  in  the  Jefferson  Medical  College  of 
Philadelphia.  To  which  is  added  the  second  American  from  the  latest  English  edition  of 
Landmauks,  Medical  and  Surgical,  by  Luther  Holden,  F.  R.  C.  S.  In  one  imperial 
octavo  volume  of  1098  pages,  with  685  large  and  elaborate  engravings  on  wood.  Price  of 
edition  in  black :  Cloth,  |6 ;  leather,  $7  ;  half  Russia,  |7.50.  Price  of  edition  in  colors 
(see  below) .  Cloth,  |7.25 ;  leather,  $8.25  ;  half  Russia,  $8.75. 

This  work  covers  a  more  extended  range  of  subjects  than  is  customary  in  the  ordinary 
text-books,  giving  not  only  the  details  necessary  for  the  student,  but  also  the  application  to 
those  details  to  the  practice  of  medicine  and  surgery.  It  thus  forms  both  a  guide  for  the 
learner  and  an  admirable  work  of  reference  for  the  active  practitioner.  The  engravings 
form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in 
place  of  figures  of  reference  with  descriptions  at  the  foot.  In  this  edition  a  new  departure 
has  been  taken  by  the  issue  of  the  work  with  the  arteries,  veins  and  nerves  distinguished 
by  different  colors.  The  engravings  thus  form  a  complete  and  splendid  series,  which  will 
greatly  assist  the  student  in  forming  a  clear  idea  of  Anatomy,  and  will  also  serve  to  refresh 
the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recall- 
ing the  details  of  the  dissecting-room!  Combining,  as  it  does,  a  complete  Atlas  of 
Anatomy  with  a  thorough  treatise  on  systematic,  descriptive  and  applied  Anatomy, 
the  work  will  be  found  of  great  service  to  all  physicians  who  receive  students  in  their 
offices,  relieving  both  preceptor  and  pupil  of  much  labor  in  laying  the  groundwork  of  a 
thorough  medical  education. 

For  the  convenience  of  those  who  prefer  not  to  pay  the  slight  increase  in  cost_  necessi- 
tated by  the  use  of  colors,  the  volume  is  published  also  in  black  alone,_  and  maintained 
in  this  "style  at  the  price  of  former  editions,  notwithstanding  its  largely  increased  size. 

Landmarks,  Medical  and  Surgical,  by  the  distinguished  Anatomist,  Mr.  Luther  Holden, 
has  been  appended  to  the  present  edition  as  it  was  to  the  previous  one.  This  work  gives 
in  a  clear,  condensed  and  systematic  way  all  the  information  by  which  the  practitioner  can 
determine  from  the  external  surface  of  the  body  the  position  of  internal  parts.  Thus 
complete,  the  work  will  furnish  all  the  assistance  that  can  be  rendered  by  type  and 
illustration  in  anatomical  study. 


The  most  popular  work  on  anatomy  ever  written. 
It  is  sufficient  to  say  of  it  that  this  edition,  thanks 
to  its  American  editor,  surpasses  all  other  edi- 
tions.—/our-,  of  the  Amer.  Med.  Ass'n,  Dec.  31, 1887. 

A  work  which  for  more  than  twenty  years  has 
had  the  lead  of  all  other  text-books  on  anatomy 
throughout  the  civilized  world  comes  to  hand  in 
such  beauty  of  execution  and  accuracy  of  text 
and  illustration  as  more  than  to  make  good  the 
large  promise  of  the  prospectus.     It  would  be  in 


books.  The  work  is  published  with  black  and 
colored  plates.  It  is  a  marvel  of  book-ma.king.— 
American  Practitioner  and  Neivs,  Jan.  21, 1888. 

Gray's  Anatomy  is  the  most  magnificent  work 
upon  anatomy  which  has  ever  been  published  in 
the  English  or  any  other  language.— Cincinwa^i 
Medical  News,  Nov.  1887. 

As  the  book  now  goes  to  the  purchaser  he  is  re- 
ceiving the  best  work  on  anatomy  that  is  published 
in  any  language. —  Virqinia  Med.  Monthly,  Dec. 1887. 


deed  difficult  to  name  a  feature  wherein  the  pres-  ^  Gray's  standard  Anatomy  has  been  and  will  be 
ent  American  edition  of  Gray  could  be  mended  for  years  the  lext-book  for  students  Ihe  book 
or  bettered,  and  it  needs  no  prophet  to  see  that  needs  only  to  be  exammed  to  be  perfectly  under- 
the  royal  work  is  destined  for  many  years  to  come  ^  stood.— Medical  Press  of  Western  New  iorK,  dan. 
to  hold   the  first  place   among  anatomical  text-  ,  1888. 


Also  fob  sale  separate — 
HOLDBN^,  LTJTSEJR,  F.  B.  C.  S., 

Surgeon  to  St.  Bartholomew's  and  the  Foundling  Hospitals,  London. 

Landmarks,  Medical  and  Surgical.  Second  American  from  the  latest  revised 
English  edition,  with  additions  by  W.  W.  Keen,  M.  D.,  Professor  of  Artistic  Anatomy  in 
the  Penn.  Academy  of  Fine  Arts.     In  one  12uio.  volume  of  148  pages.     Cloth,  i?l.UU 

DUJ^GLISOJ^,  BOBLFY,  M,D., 

Late  Professor  of  Listitutes  of  Medicine  in  the  Jefferson  Medical  College  of  Philadelphia. 

MEDICAL  LEXICON;  A  Dictionary  of  Medical  Science :  Containing 

a  concise  Explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology,  Pathol- 
ogy, Hygiene,  Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  MedicalJiiris- 
pmdencl  and  Dentistry,  Notices  of  Climate  and  of  Mineral  Waters,  Formula  for  Officinal, 
Empirical  and  Dietetic  Preparations,  with  the  Accentuation  and  Etymology  of  the  Ter)^ 
and  the  French  and  other  Synonymes,  so  as  to  constitute  a  French  as  well  as  an  English 
Medical  Lexicon.  Edited  by  Richaud  J.  I>?^^«Pif '  ^^-^I^- J^  «^«  J^^^  i^fv^^n^ 
handsome  royal  octavo  volume  of  1139  pages.  Cloth,  $6.50 ;  leather,  raised  bands,  $7.50 ; 
very  handsome  half  Russia,  raised  bands,  $8. 

It  has  the  rare  merit   that  it  certainly  has  no  rival   in  the  English  language  for  accuracy 
and  extent  of  references.— io?ido?i  Medical  Gazette. 


6  Lea  Brothers  &  Co.'s  Publications — Anatomy. 

AJ.LEN,  HAHBISON,  M,  !>., 

Prnftssor  of  Physiology  in  the  University  of  Pennsylvania. 

A  System  of  Hvunan  Anatomy,  Including  Its  Medical  and  Surgical 
Helations.  For  tlie  use  of  Practitioners  and  Students  of  Me<licine.  With  an  Intro- 
ductory Section  on  Histology.  By  E.  O.  SHAKf>=PEARE,  M.  D.,  <)j>hthalniologist  to 
the  Philadelphia  Hosjiital.  Comprising  813  double-columned  quarto  pages,  with  380 
illustrations  on  109  full  page  lithographic  plates,  many  of  which  are  in  colors,  and  241 
engravings  in  the  text.  In  six  Sections,  each  in  a  portfolio.  Section  I.  Histology. 
Section  II.  Bones  and  Joints.  Section  III.  Muscles  and  Fascije.  Section  IV. 
Arteries,  Veins  and  Lymphatics.  Section  V.  Nervous  System.  Section  VI. 
Organs  of  Sense,  of  Digestion  and  Gexito-Urinary  Organs,  Embryology, 
Develop.ment,  Teratology,  Suterficial  Anatomy,  Post-Mortem  Examinations, 
AND  General  and  Clinical  Indexes.  Price  per  Section,  $3.50;  also  bound  in  one 
volume,  cloth,  $23.00 ;  very  handsome  half  Russia,  raised  bands  and  open  back,  $25.00. 
For  sale  by  subscription  only.     Apply  to  the  Publishers. 

It  is  to  rx"  ooDPiderPd  a  study  of  applied  anatomy  care,  and  are  simply  superb.    There   13  as  much 

in  it.«  widest  sense — a  systematic  presentation  of  of   practical   application  of  anatomical   points  to 

such   anatomical  facts  as  can   be  applied   to  the  the  eyery-day  wants  of   the  medical  clinician  as 

practice  of  medicine  as  well  as  of  surgery.    Our  to  those  of   tne  operating  surgeon.    In  fact,  few 

author  is  concise,  accurate  and  practical   in   his  general  practitioners  will  read  the  work  without » 

statements,  and   succeeds  admirably  in  infusing  feeling  of   surprised   gratification    that  so  many 

an  interest  into  the  studv  of  what  is  generally  con-  point.s,  concerning  which  they  may  never  hare 

Bidered  a  dry  subject,    "f  he  department  of  flistol-  thought  before  are  so  well  presented" I'or  their  con- 

ogy   is   treated   in  a    masterly  manner,  and    the  sideration.    It  is  a  work  which  is  destined  to  be 

ground  is  travelled  over  by  one  thoroughly  famil-  the  best  of  its  kind   in    any  language. — Medical 

lar  with  it    The  illustrations  are  made  witn  great  Record,  Nov.  25, 1882. 


CLARKE.W.  B,,  F.B.C.S.  &  LOCKWOODyC.  B.,  F.B.C.S, 

Demonstrators  of  Anatomy  at  St.  Bartholomeic''s  Hospital  Medical  School,  London. 

The  Dissector's  Manual.     In  one  pocket-size  12rao.  volume  of  396  pages,  with 
49  illustratifms.     Limj)  cloth,  red  edges,  $1.50.     See  Students'  Series  of  Manuals,  page  31. 

Messrs.Clarke  and  Lock  wood  have  written  a  book  intimate  association  with  students  could  have 
that  can  hardly  be  rivalled  as  a  practical  aid  to  the  given.  With  such  a  guide  as  this,  accompanied 
dissector.  Their  purpose,  which  is  "how  to  de-  by  so  attractive  a  commentary  as  Treves' iurj^teoJ 
scribe  the  best  way  to  display  the  anatomical  Applied  Anatomy  (ii&me  series),  no  student  could 
structure,"  has  been  fully  attained.  They  excel  in  fail  to  be  deeplyand  absorbingly  interested  in  the 
a  lucidity  of  demonstration  and  graphic  terseness  study  of  anatomy. — yew  Orleans  JJedical  and  Sur- 
of  expression,  which  only  a  long  training  and    giecU  Journal,  April,  1884. 


IBEVBS,  FBBDBBICK,  F.  B.  C,  S., 

Senior  Demonstrator  of  Anatomy  and  Assistant  Surgeon  at  the  London  Hospital. 

Surgical  Applied  Anatomy.  In  one  pocket-size  12mo.  volume  of  540  pages, 
with  61  illustrations.  Limp  cloth,  red  edges,  $2.00.  See  Students'  Series  of  Manuals^ 
page  31. 

He  has  produced  a  work  which  will  command  a  This  number  of  the  "Manuals  for  Students"  is 
larger  circle  of  readers  than  the  cla-^s  for  which  it  most  excellent,  giving  just  such  practical  knowl- 
was  written.  Thi.«union  of  a  thorough,  practical  edge  as  will  be  required  for  application  in  relieving 
acquaintance  with  these  fundamental   branches,    the  injuries    to  which  the  living  body  is  liable. 

?uir-kened  by  daily  use  sis  a  teacher  and  practl-  The  book  is  intended  mainly  for  students,  but  it 
ioner,  has  enabled  our  author  to  prepare  a  work  will  also  be  of  great  use  to  practitioners.  Theilluo- 
which  it  would  be  a  most  difficult  task  to  excel.—  trations  are  well  executed  and  fully  elucidate  the 
The  American  Practitioner,  Feb.  1884.  ,  text.— Southern  Practitioner,  Feb.  1884. 


BELLAMY,  EDWABD,  F.  B.  C.  S., 

Senior  Assistant-Surgeon  to  the  Charing-Cyoss  Hoipital,  London. 

The  Student's  Guide  to  Surgical  Anatomy :  Being  a  Description  of  the 
most  lmjK)rtant  Surgical  Regions  of  the  Human  Body,  and  intended  as  an  Introduction  to 
operative  Surgery.    In  one  12mo.  volume  of  300  pages,  with  50  illustrations.    Cloth,  $2.25. 

WILSOK,  EBAS31US,  F.  B,  S, 

A  System  of  Human  Anatomy,  General  and  Special.  Edited  by  W.  H. 
Goerecht,  M.D.,  Profess<^)r  of  General  and  Surgical  Anatomy  in  the  Medical  College  of 
Ohio.  In  one  large  and  handsome  octavo  volume  of  616  pages,  with  397  illustrations. 
Cloth,  $4.00;  leather,  $5.00.  

CLELAJSn,  JOffJ!f,  M.  I).,  F,  B.  S., 

Professor  of  Anatomy  and  Physiology  in  Queen's  College,  Galway. 

A  Directory  for  the  Dissection  of  the  Human  Body.  In  one  12mo. 
volume  of  178  pages.     Cloth,  $1.25. 


HARTSHORNES    HANDBOOK    OF    ANATOMY  HORNER'S  SPECIAL  ANATOMY  AND  HISTOLr 

AND  PHYSIOLOGY.    Second  edition,  revised.  OGY.    Eighth  edition,  extensively  revised  and 

In  one  royal  12mo.  volume  of  310  pages,  with  220  modified.    In  two  octavo  volumes  of  10)7  pages, 

woodcuts.     Cloth,  $1.75.  with  320  woodcuts.    Cloth,  86.00. 


Lea  Brothers  &  Co.  s  Publications — Physics,  Pliysiol.,Anat.        7 

Professor  of  Chemistry  in  the  University  of  the  City  of  New  York. 
Medical  Physics.     A  Text-book  for  Students  and  Practitioners  of  Medicine.    In 
one  octavo  volume  of  734  pages,  with  376  woodcuts,  mostly  original.   Cloth,  |4. 

FROM  THE  PREFACE. 
The  fact  that  a  knowledge  of  Physics  is  indispensable  to  a  thorough  understanding  of 
Medicine  has  not  been  as  fully  realized  in  this  country  as  in  Europe,  where  the  admirable 
works  of  Desplats  and  Gariel,  of  Kobertson  and  of  numerous  German  writers  constitute  a 
branch  of  educational  literature  to  which  we  can  show  no  parallel.  A  full  appreciation 
of  this  the  author  trusts  will  be  sufficient  justification  for  placing  in  book  form  the  sub- 
stance of  his  lectures  on  this  department  of  science,  delivered  during  many  years  at  the 
University  of  the  City  of  New  York. 

Broadly  speaking,  this  work  aims  to  impart  a  knowledge  of  the  relations  existing 
between  Physics  and  Medicine  in  their  latest  state  of  development,  and  to  embody  in  the 
pursuit  of  this  object  whatever  experience  the  author  has  gained  during  a  long  period  of 
teaching  this  special  branch  of  applied  science. 

This  elegant  and  useful  work  bears  ample  testl-  I  explained,  acoustics,  optics,  heat,  electricity  and 
mony  to  the  learning  and  good  judgment  of  the  magnetism,  closing  with  a  section  on  electro- 
author.  He  has  fitted  his  work  admirably  to  the  !  biology.  The  applications  of  all  these  to  physiology 
exigencies  of  the  situation  by  presenting  the  I  and  medicine  are  kept  constantly  in  view.  The 
reader  with  brief,  clear  and  simple  statements  of  ;  text  is  amply  illustrated  and  the  many  difficult 
such  propositions  as  he  is  by  necessity  required  to  I  points  of  the  subject  are  brought  forward  with  re- 
master. The  subject  matter  is  well  arranged,  markable  clearness  and  ability. — Medical  and  Surg- 
liberally  illustrated  and  carefully  indexed.     That  !  ical  Reporter,  July  18, 1885. 

it  will  take  rank  at  once  among  the  text-books  is  That  this  work  will  greatly  facilitate  the  study 
certain,  and  it  is  to  be  hoped  that  it  will  find  a  I  of  medical  physics  is  apparent  upon  even  a  mere 
place  upon  the  shelf  of  the  practical  physician.  I  cursory  examination.  It  is  marked  by  that  scien- 
where,  as  a  book  of  reference,  it  will  be  found  !  tific    accuracy    which   always   characterizes   Dr. 


useful  and    agreeable. — Louisville   Medical   News, 
September  26,  1885. 

Certainly  we  have  no  text-book  as  full  as  the  ex- 
cellent one  he  has  prepared.  It  begins  with  a 
statement  of  the  properties  of  matter  and  energy. 
After  these  the  special  departments  of  physics  are 


Draper's  writings.  Its  peculiar  value  lies  in  the 
fact  that  it  is  written  from  the  standpoint  of  the 
medical  man.  Hence  much  is  omitted  that  ap- 
pears in  a  mere  treatise  on  physical  science,  while 
much  is  inserted  of  peculiar  value  to  the  physi- 
cian.— Medical  Record,  August  22,  1885. 


BOBJEnTSON,  J,  McGBBGOB,  M.  A.,  M.  B., 

Muirhead  Demonstrator  of  Physiology,  University  of  Glasgow. 
Physiological  Physics.     In  one  12mo.  volume  of  537  pages,  with  219  illustra- 
tions.    Limp  cloth,  $2.00.     See  Students'  Series  of  Manuals,  page  31. 

The  title  of  this  work  sufficiently  explains  the  i  ments.  It  will  be  found  of  great  value  to  the 
nature  of  its  contents.  It  is  designed  as  a  man-  I  practitioner.  It  is  a  carefully  prepared  book  of 
ual  for  the  student  of  medicine,  an  auxiliary  to  reference,  concise  and  accurate,  and  as  such  we 
his  text-book  in  physiology,  and  it  would  be  particu-  ,  heartily  recommend  it— Journal  of  the  American 
larly  useful  as  a  guide  to  his  laboratory  expert-  i  Medical  Association,  Dec.  6, 1884. 

DALTOW,  JOSW  a,  M.  D., 

Professor  Emeritus  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  Neio  York. 

Doctrines  of  the  Circulation  of  the  Blood.  A  History  of  Physiological 
Opinion  and  Discovery  in  regard  to  the  Circulation  of  the  Blood.  In  one  handsome 
12mo.  volume  of  293  pages.     Cloth,  $2. 

Dr  Dalton's  work  is  the  fruit  of  the  deep  research  |  revolutionized  the  theories  of  teachers,  than  the 
of  a  cultured  mind,  and  to  the  busy  practitioner  it  discovery  of  the  circulation  of  the  blood.  Ihls 
cannot  fail  to  be  a  source  of  instruction.  It  will  explains  the  extraordinary  mterest  it  has  to  all 
inspire  him  with  a  feeling  of  gratitude  and  admir-  medical  historians._  The  volume  before  us  is  one 
ation  for  those  plodding  workers  of  olden  times,  of  three  or  four  which  have  been  written  within  a 
who  laid  the  foundation  of  the  magnificent  temple  few  years  by  American  physicians.  It  is  in  several 
of  medical  science  as  it  now  stands.— iVew  Orleans  '  respects  the  most  complete.  The  volume,  though 
Medical  and  Surgical  Journal,  Aug.  1885.  !  small  in  size,  is  one  of  the  most  creditable  con- 

In  the  progress  of  physiological  study  no  fact  |  t^butionsfroman  American  pen  to  medical  history 
was  of   greater  moment,  none  more  completely  !  that  has  appeared.— ilfed.  d;  Surg.  Rep.,  Dec.  6, 1884. 

BJELL,  F.  JEFFREY,  M,  A., 

Professor-  of  Comparative  Anatomy  at  King's  College,  London. 

Comparative  Physiology  and  Anatomy.  In  one  12mo.  volume  of  561  pages, 
with  229  illustrations.  Limp  cloth,  $2.00.     See  Students'  Series  of  Manuals,  page  ol. 

The  manual  is  nreeminentlv  a  student's  book—  it  the  best  work  in  existence  in  the  English 
clJara^^simple'^'nSnguage  and  arrangement.  ;  language  to  place  in  the  hands  of  the  me^ic^ 
lUs  wTandTundantly^illustrated,  andls  read-  I  stadent.-Bristol  Medico-Chirurgical  Journal,  Mar. 
able  and  interesting.    On  the  whole  we  consider  I  1886. 

BLLIS,  GEOBGE  VINEB, 

Emeritus  Professor  of  Anatomy  in  University  College,  London. 

Demonstrations  of  Anatomy.  Being  a  Guide  to  the  Knowledge  of  the 
Human  Body  by  Dissection.  From  the  eighth  and  revised  London  edition.  In  one  veiy 
handsome  octavo  volume  of  716  pages,  with  249  illustrations.   Cloth,  $4.25;  leather,  $5.25. 

ROBERTS,  JOHW  B.,  A.  M.,  M.  I)., 

Prof  of  Applied  Anat.  and  Oper.  Surg,  in  Phila.  Polyclinic  and  Coll.  or  Graduates  m  Medicine. 
The  Compend  of  Anatomy.     For  use  in  the  dissecting-room  and  in  preparing 
for  examinations     In  one  16mo.  volume  of  196  pages.     Limp  cloth,  7o  cents. 


8        Lea  Brothers  &  Co.'s  Publications — Physiology,  Chemistry. 


CMABMANf  HENRY  C,  M,  D., 

Professor  of  Institutes  of  Medicine  and  Medicn'  Juris,  in  the  Jefferson  Med.  Coll.  of  Philadelphia. 

A  Treatise  on  Human  Physiology.     In  one  liandsome  octavo  volume  of 
925  pages,  with  605  fine  engravings.     Cloth,  $5.50;  leather,  $6.50. 

It  represents  very  fully  the  existing  state  of    farther,  and  the  latter  will  find  entertainment  and 
physiology.    The  present  work  has  a  special  value    instruction  in  an  admirable  book  of  reference. — 


to  the  student  and  practitioner  as  devoted  more  Aorth  Carolina  Medical  Journal,  Hoy.  1SS7. 
to  the  practical  application  of  well-known  truths 
which  the  advance  of  science  has  given  to  the 
profession  in  this  department,  which  may  be  con- 
sidered the  foundation  of  rational  medicine. — Buf- 
falo Medical  ntui  Surgical  Journal,  I)ec.l8Si7. 

Matteis  which  have  a  piactical  bearing  on  the 
practice  of  medicine  are  lucidly  expressed;  tech- 
nical matters  are  given  in  minute  detail;  elabo- 
rate directions  are  stated  for  the  guidance  of  stu- 
dents in  the  laboratory.  In  every  respect  the 
work  fulfils  its  promise,  whether  as  a  complete 
treatise  for  the  student  or  for  the  physician  ;  for 


The  work  certainly  commends  itself  to  both 
student  and  practitioner.  What  is  most  demanded 
by  the  progressive  physician  of  to-day  is  an  adap- 
tation of  physiology  to  practical  therapeutics,  and 
this  work  is  a  decided  improvement  in  this  res()ect 
over  other  works  in  the  market.  It  will  certainly 
take  place  among  the  most  valuable  text-books. — 
Medical  Age,  Nov.  25,  1887. 

It  is  the  production  of  an  author  delighted  with 
his  work,  and  able  to  inspire  students  with  an  en- 
thusiasm akin  to  his  own. — American  Practitioner 


the  former  it  is  so  complete  that  he  need  look  no  |  and  J\'etcs,  Nov.  12, 1887. 

DALTOJSr,  JOHN  C,  MTIx, 

Professor  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New  York,  etc. 
A  Treatise  on   Human  Physiology.      Designed  for  the  use  of  Students  and 
Practitioners  of  Medicine.     Seventh  edition,  thoroughly  revised  and  rewritten.     In  one 
verv  handsome  octavo  volume  of  722  pages,  with  252  beautiful  engravings  on  wood.    Cloth, 
$5.00;  leather,   $6.00. 

From  the  first  appearance  of  the  book  it  has  1  have  never  been  in  any  doubt  as  to  its  sterling 
been  a  favorite,  owing  as   well   to    the    author's  j  wojth. — N.  i\  Medical  Journal,  Oct.  1882. 


renown  as  an  oral  teacher  as  to  the  charm  of 
simplicity  with  which,  as  a  writer,  he  always 
succeed.-*  in  investing  even  intricate  subjects. 
It  must  be  gratifying  to  him  to  observe  the  fre- 
quency with  which  his  work,  written  for  .'■tndent 


Professor  Dalton's  well-known  and  deservedly- 
appreciated  work  has  long  passed  the  stage  at 
which  it  could  be  reviewed  in  the  ordinarj'  sense. 
The  work  is  eminently  one  for  tlie  medical  prac- 
titioner, since  it  treats  most  fully  of  those  branches 


and  practitioners,  is  quoted  by  other  writers  on  i  of  physiology  which  have  a  direct  bearing  on  the 
physiology.  This  fact  attests  its  value,  and,  in  diagnosis  and  treatment  of  disease.  The  work  is 
great  measure,  its  originality.  It  now  needs  no  one  which  we  can  highly  recommend  to  all  our 
such  seal  of  approbation,  however,  for  tlie  thou-  j  readers. — I>ublin  Journal  of  Medical  Science,  Feb. '83. 
Bands  who  have  studied  it  in  its  various  editions  ] 

FOSTER,  MICHAEL,  M,  I).,  F.  R,  S., 

Prelector  in  Physiology  and  Fellow  of  Trinity  College,  Cambridge,  England. 
Text-Book  of  Physiology.     New  (fourth)  and   enlarged  American  from  the 
fifth  and  revised  English  edition,  with  notes  and  additions.     Prepurincj. 

A  REVIEW  OF  THE  FIFTH  ENGLISH  EDITION  IS  APPENDED. 
It  is  delightful  to  meet  a  book  which  deserves  ■  tions,  and  his  energies  are  not  frittered  away  and 
only  unqualified  praise.  Such  a  book  is  now  before  degenerated  on  petty  and  trivial  details.  Review- 
us.  It  is  in  all  respects  an  ideal  text-book.  With  a  ing  this  volume  as  a  whole  we  are  justified  in  say- 
complete,  accurate  and  detailed  knowledge  of  his  ing  that  it  is  the  only  thoroughly  good  text-book 
subject,  the  author  has  succeeded  in  giving  a  '  of  physiology  in  the  English  language,  and  that  it 
thoroughly  consecutive  and  philosophic  account '  is  probably  "the  best  te.xt-book  in  any  language, 
of  the  science.  A  student's  attention  is  kept  — Edinburgh  Medical  Journal,  December  1889. 
throughout  fixed  on  the  great  and  salient  ques-  i 

FOWER,  HENRY,  M.  B.,  F.  R.  C.  S., 

Examiner  in  Physiology,  Soyal  College  of  Surgeons  of  England. 
Human  Physiology.     Second  edition.     In  one  handsome  pocket-size  12mo.  vol- 
ume of  396  pp.,  with  47  illustrations.    Cloth,  $1.50.    See  Students^  Series  of  Manuals,  p.  31. 

SIMON,  W.,  FJi.  H,,  M.  n., 

Professor  of  Chemistry  and  Toxicology  in  the  College  of  Physicians  and  Surgeons,  Baltimore,  and 
Professor  of  Chemistry  m  the  Maryland  College  of  Pharmacy. 

Manual  of  Chemistry.  A  Guide  to  Lectures  and  Laboratory  work  for  Beginners 
in  Chemistry.  A  Text-book,  specially  adapted  for  Students  of  Pharmacy  and  Medicine. 
Kew  (second)  edition.  In  one  8vo.  vol.  of  478  pp.,  with  44  woodcuts  and  7  colored  plates 
illustrating  56  of  the  most  important  chemical  tests.     Cloth,  $3.25. 


In  this  book  the  author  has  endeavored  to  meet 
the  wants  of  the  student  of  medicine  or  pharmacy 
in  regard  to  his  chemical  studies,  and  he  has  suc- 
ceeded in  presenting  his  subject  so  clearly  that  no 
one  who  really  wishes  to  acquire  a  fair  knowledge 
of  chemistry  can  fail  to  do  so  with  the  help  of  this 
work.  The  largest  section  of  the  book  is  naturally 
that  devoted  to  the  consideration  of  the  carbon 
compounds,  or  organic  chemistry.    An  excellent 


feature  is  the  introduction  of  a  number  of  plates 
showing  the  various  colors  of  the  most  important 
chemical  reactions  of  the  metallic  salts,  of  some 
of  the  alkaloids,  and  of  the  urinary  tests.  In  the 
part  treating  of  physiological  chemistry  the  section 
on  analysis  of  tne  urine  will  be  found  very  practi- 
cal, and  well  suited  to  the  needs  of  the  practitioner 
of  medicine.— r/ie  Medical  Record,  May  25, 1889. 


Wohler's  Outlines  of  Organic  Chemistry.     Edited  by  Fittig.    Translated 
by  Ika  Eemsen,  M.  D.,  Ph.  D.     In  one  12mo.  volume  of  550  pages.     Cloth,  $3. 


LEHMANN'S  MANUAL  OF  CHEMICAL  PHYS- 
IOLOGY. In  one  octavo  volume  of  327  pages, 
with  41  illustrations.    Cloth,  82.25. 

CARPENTER'S  HUMAN  PHYSIOLOGY.  Edited 
by  Heset  Powf.e.    In  one  octavo  volume. 


CARPENTER'S  PRIZE  ESSAY  ON  THE  USE  AND 
Abuse  OF  Alcoholic  Liquors  in  Health  and  Dis- 
ease. With  explanations  of  scientific  words.  Small 
12mo.    178  pages.    Cloth,  60  cents. 


Lea  Brothers  &  Co.'s  Publications — Chemistry. 


FBANKLANn,  B.,  JD.  C.  L.,  F.  B.S.,&  J  AFP,  F.  M.,  F.  I,  C, 


Professor  of  Chemistry  in  the  Normal  School 
of  Science,  London. 


Assist.  Prof,  of  Cliemistry  in  the  Normal 
School  of  Science,  London, 


Inorganic  Chemistry.     In  one  handsome  octavo  volume  of  677  pages  with  51 
woodcuts  and  2  plates.     Cloth,  $3.75  ;  leather,  $4.75. 


This  work  should  supersede  other  works  of  its 
class  in  the  medical  colleges.  It  is  certainly  better 
adapted  than  any  work  upon  chemistry,with  which 
we  are  acquainted,  to  impart  that  clear  and  full 
knowledge  of  the  science  which  students  of  med- 
icine should  have.  Physicians  who  feel  that  their 
chemical  knowledge  is  behind  the  times,  would 
do  well  to  devote  some  of  their  leisure  time  to  the 
study  of  this  work.  The  descriptions  and  demon- 
strations are  made  so  plain  that  there  is  no  diffi- 
culty in  understanding  them. — Cincinnati  Medical 
Neivs,  January,  1886.  


This  excellent  treatise  will  not  fail  to  take  its 
place  as  one  of  the  very  best  on  the  subject  of 
which  it  treats.  We  have  been  much  pleased 
with  the  compreliensive  and  lucid  manner  in 
which  the  difficulties  of  chemical  notation  and 
nomenclature  have  been  cleared  up  by  the  writers. 
It  shows  on  every  page  that  the  problem  of 
rendering  the  obscurities  of  this  science  easy 
of  comprehension  has  long  and  successfully 
engaged  the  attention  of  the  authors. — Medical 
and  Surgical  Reporter,  October  31,  1885. 


FOWNBS,  GFOMGF,  Fh,  Z>. 

A  Manual  of  Elementary  Chemistry;  Theoretical  and  Practical.  Em- 
bodying Watts'  Physical  Inorganic  Chemistry.  New  American,  from  the  twelfth  English 
edition.  In  one  large  royal  12mo.  volume  of  1061  pages,  with  168  illustrations  on  wood 
and  a  colored  plate.     Cloth,  $2.75 ;  leather,  $3.25. 

Fovones'  Chemistry  has  been  a  standard  text- 
book upon  chemistry  for  many  years.  Its  merits 
are  very  fully  known  by  chemists  and  physicians 
everywhere  in  this  country  and  in  England.  As 
the  science  has  advanced  by  the  making  of  new 
discoveries,  the  work  has  been  revised  so  as  to 
keep  it  abreast  of  the  times.  It  has  steadily 
maintained  its  position  as  a  textbook  with  medi- 
cal students.  In  this  work  are  treated  fully:  Heat, 
Light  and  Electricity,  including  Magnetism.  The 
influence  exerted  by  these  forces  in  chemical 
action  upon  health  and  disease,  etc.,  is  of  the  most 
important  kind,  and  should  be  familiar  to  every 
medical  practitioner.  We  can  commend  the 
work  as  one  of  the    very  best  text-books    upon 


chemistry  extant. — Cincinnati  Medical  News,  Oc- 
tober, 1885. 

Of  all  the  works  on  chemistry  intended  for  the 
use   of  medical    students,   Fownes'   Chemistry    is 

Eerhaps  the  most  widely  used.  Its  popularity  is 
ased  upon  its  excellence.  This  last  edition  con- 
tains all  of  the  material  found  in  the  previous, 
and  it  is  also  enriched  by  the  addition  of  Watts' 
Physical  and  Inorganic  Chemistry.  All  of  the  mat- 
ter is  brought  to  the  present  standpoint  of  chemi- 
cal knowledge.  We  may  safely  predict  for  this 
work  a  continuance  of  the  fame  and  favor  it  enjoys 
among  medical  students. — iVeio  Orleans  Medical 
and  Surgical  Journal,  March,  1886. 


ATTFIFZI>,  JOMN,  Fh,  !>., 

Professor  of  Practical  Chemistry  to  the  Pharmaceutical  Society  of  Great  Britain,  etc. 

Chemistry,  General,  Medical  and  Pharmaceutical ;  Including  the  Chem- 
istry of  the  U.  S.  Pharmacopoeia.  A  Manual  of  the  General  Principles  of  the  Science, 
and  their  Application  to  Medicine  and  Pharmacy.  A  new  American,  from  the  twelfth 
English  edition,  specially  revised  by  the  Author  for  America.  In  one  handsome  royal 
12mo.  volume  of  782  pages,  with  88  illustrations.   Cloth,  $2.75 ;  leather,  $3.25.   Just  ready. 

again  it  is  a  good  laboratory  guide,  and  finally  it 
contains  such  a  mass  of  well-arranged  information 
that  it  will  always  serve  as  a  handy  book  of  refer- 


Attfield's  Chemistry  is  the  most  popular  book 
among  students  of  medicine  and  phar  maey.  This 
popularity  has  a  good,  substantial  basis.  It  rests 
upon  real  merits.  Attfield's  work  combines  in  the 
happiest  manner  a  clear  exposition  of  the  theory 
of  cnemislry  with  the  practical  application  of  this 
knowledge  to  the  everyday  dealings  of  the  phy- 
sician and  pharmacist.  His  discernment  is  shown 
not  only  in  what  he  puts  into  his  work,  but  also  in 
what  he  leaves  out.  His  book  is  precisely  what 
the  title  claims  for  it.  The  admirable  arrangement 
of  the  text  enables  a  reader  to  get  a  good  idea  of 
chemistry  without  the  aid  of  experiments,  and 


ence.  He  does  not  allow  anyunutilizable  knowl- 
edge to  slip  into  his  book;  his  long  years  of 
experience  have  produced  a  work  whicli  is  both 
scientific  and  practical,  and  which  shuts  out 
everything  in  tne  nature  of  a  superfluity,  and 
therein  lies  the  secret  of  its  success.  This  last 
edition  shows  the  marks  of  the  latest  progress 
made  in  chemistry  and  chemical  teaching.— /Vew 
Orleans  Medical  and  Surgical  Journal,  Nov.  1889. 


BLOXAM,  CHARLES  i.. 

Professor  of  Chemistry  in  King's  College,  London. 
Chemistry,  Inorganic   and   Organic.     New  American  from  the  fifth  Lon- 
don  edition,   thoroughly  revised   and  much   improved.     In  one  very  handsome  octavo 
volume  of  727  pages,  with  292  illustrations.     Cloth,  $2.00 ;  leather,  $3.00 

Comment  from  us  on  this  standard  work  is  al- 
most superfluous.  It  differs  widely  in  scope  and 
aim  from  that  of  Attfield,  and  in  its  way  is  equally 
beyond  criticism.  It  adopts  the  most  direct  meth- 
ods in  stating  the  principles,  hypotheses  and  facts 
of  the  science.  Its  language  is  so  terse  and  lucid, 
and  its  arrangement  of  matter  so  logical  in  se- 
quence that  the  student  never  has  occasion  to 
complain  that  chemistry  is  a  hard  study.  Much 
attention  is  paid  to  experimental  illustrations  of 
chemical  principles  and  phenomena,  and  the 
mode  of  conducting  these  experiments.  The  book 
maintains  the  position  it  has  always  held  as  one  of 


the  best  manuals  of  general  chemistry  In  the  Eng- 
lish language.— Detroii  Lancet,  Feb.  1884. 

We  know  of  no  treatise  on  chemistry  which 
contains  so  much  practical  information  in  the 
same  number  of  pages.  The  book  can  be  readily 
adapted  not  only  to  the  needs  of  those  who  desire 
a  tolerably  complete  course  of  chemistry,  but  also 
to  the  needs  of  those  who  desire  only  a  general 
knowledge  of  the  subject.  We  take  pleasure  m 
recommending  this  work  both  as  a  satisfactory 
text- book,  and  as  a  useful  book  of  reference.— les- 
ion Medical  and  Surgical  Journal,  June  19, 1884. 


GMEENF,  WILLIAM  Jff.,  M,  J>., 

Demonstrator  of  Chemistry  in  the  Medical  Department  of  the  University  of  Pennsylvania. 
A  Manual  of  Medical  Chemistry.    For  the  use  of  Students.  ...Based  upon  Bow. 
man's  Medical  Chemistry.   In  one  12mo.  volume  of  310  pages,  with  74  lUus.    Cloth,  3)1. /O. 

It  is  a  concise  manual  of  three  hundred  pages,  1  the  recognition  of  compounds  due  to^^^^^^ 
giving  an  excellent  summary  of  the  best  methods     conditions..    The  detection  of  poisons  ^s  treatea 
of  analyzing  the  liquids  and  solids  of  the  body,  both     with  sufficient  fulness  for  the  purpo^^^^^ 
for  the  estimation  of  their  normal  constituent  and  1  dent  or  practitioner.-£oston  JL  oj  o/iem.  Juu«,  ov. 


10  Lea  Brothers  &  Co.'s  Publications — Chemistry. 

BJE3ISEK,  IBA,  M,  J).,  Ph,  D., 

Professor  of  Chemistry  in  the  Johns  Hopkins  University,  Baltimore' 
Principles  of  Theoretical  Chemistry,  with  special  reference  to  the  Constitu- 
tion of  Clieniical  ComjxMinds.    New  (tliird)  and  tliorouglily  revised  edition.    In  one  hand- 
some royal  r2mo.  vohime  of  316   pages.     Cloth,  $2.00 

This  work  of  Dr.  Renisen  is  the  very  test-book  examination  of  college  facilities  as  t/ie  text^bookof 
needed,  and  tlie  medical  student  who  has  it  at  chemical  instruction.— S/.  Louis  Medical  and  Sur- 
his  fingers'  ends,  so  to  speak,  can,  if  he  chooses,    (jim/  Jintrnnl,  January,  18S8. 

make  himself  familiar  with  any  branch  of  chem-  "  It  is  a  healthful  sign  when  we  see  a  demand  for 
Istry  which  he  may  desire  to  pursue.  It  would  be  a  third  edition  of  such  a  book  as  this.  This  edi- 
difficult  indeed  to  find  a  more  lucid,  full,  and  at  tion  is  larger  than  the  last  by  about  seventy-five 
the  same  time  compact  explication  of  the  philos-  pages,  and  much  of  it  has  been  rewritten,  thus 
ophy  of  chemistry,  than  the  book  before  us,  and  bringing  it  fully  abreast  of  the  latest  investiga- 
we  recommend  it   to  the  careful   and   impartial    tions.— TS'.  Y.  Medical  Journal,  Dec.  .31, 1887. 

CHARLES,  T,  CRANSTOUN,  M,  D.,  F.  C.  S,,  M.  S., 

Formerly  Asst.  Prof,  and  Demonst.  of  Chemistry  aiui  Chemical  Physics,  Queen's  College,  Belfast. 

The  Elements  of  Physiological  and  Pathological  Chemistry.     A 

Handbook  for  Medical  Students  and  Practitioners.  Containing  a  general  account  of 
Nutrition,  Foods  and  Digestion,  and  the  Chemistry  of  the  Tissues,  Organs,  Secretions  and 
Excretions  of  the  Body  in  Health  and  in  Disease.  Together  with  the  metliods  for  pre- 
paring or  separating  their  chief  constituents,  as  also  for  their  examination  in  detail,  and 
an  outline  syllabus  of  a  practical  course  of  instruction  for  students.  In  one  handsome  octavo 
volume  of  46.3  pages,  with  38  woodcuts  and  1  colored  plate.     Cloth,  $3.50. 

Dr.  Charles  is  fully  impressed  with  the  import-  nowadays.  Dr.  Charles  has  devoted  much  space 
ance  and  practical  reach  of  his  subject,  and  he  to  the  elucidation  of  urinary  mysteries.  He  does 
has  treated  it  in  a  competent  and  instructive  man-  this  with  much  detail,  and  yet  in  a  practical  and 
ner.  We  cannot  recommend  a  better  book  than  intelligible  manner.  In  fact,  the  author  has  filled 
the  present.  In  fact,  it  fills  a  gap  in  medical  textr  his  book  with  many  practical  hinta.— Medical  Ree- 
books,  and  that  is  a  thing  which  can  rarely  be  said  1  ord,  December  20,  1884. 

HOFFMAJS^N,  F.,  J.ilf.,  P/i.2).,   &  FOWER  F.B.,  Fh.D,, 

Public  Analyst  to  the  State  of  Neiv  York.  Prof,  of  Anal.  Chem.  in  the  Phil.  Coll.  of  Pharmacy. 

A  Manual  of  Chemical  Analysis,  as  applied  to  the  Examination  of  Medicinal 
Chemicals  and  their  Preparations.  Being  a  Guide  for  the  Determination  of  their  Identity 
and  Quality,  and  for  the  Detection  of  Impurities  and  Adulterations.  For  the  use  of 
Pharmacist.s,  Physicians,  Druggists  and  Manufacturing  Chemists,  and  Pharmaceutical  and 
Medical  Students.  Third  edition,  entirely  rewritten  and  much  enlarged.  In  one  very 
handsome  octavo  volume  of  621  pages,  with  179  illustrations.    Cloth,  $4.25. 

We  congratulate  the  author  on  the  appearance  tion  of  them  singularly  explicit.  Moreover,  it  is 
of  the  third  edition  of  this  work,  published  for  the  exceptionally  free  from  typographical  errors.  We 
first  time  in  this  country  also.  It  is  admirable  and  have  no  hesitation  in  recommending  it  to  those 
the  information  it  undertakes  to  supply  is  both  who  are  engaged  either  in  the  manufacture  or  the 
extensive  and  trustworthy.  The  selection  of  pro-  testing  of  medicinal  chemicals. — London  Pharma- 
cesses  for  determining  the  purity  of  the  substan-  i  ceutical  Journal  and  Transactions,  1883. 
ces  of  which  it  treats  is  excellent  and  the  descrip-  j 

CLOWES f  FRANK,  1>.  Sc,  London, 

Senior  Science- Master  at  the  High  School,  Neiccastle-under-Lyme,  etc. 

An  Elementary  Treatise  on  Practical  Chemistry  and  Qualitative 
Inorganic  Analysis.  Specially  adapted  for  use  in  the  Laboratories  of  Schools  and 
Colleges  and  by  Beginners.  Third  American  from  the  fourth  and  revised  English  edition. 
In  one  very  handsome  royal  12mo.  volume  of  387  pages,  with  55  illustrations.  Cloth, 
$2.50, 


This  work  has  long  been  a  favorite  with  labora- 
tory instructors  on  account  of  its  systematic  plan, 
carrying  the  student  step  by  step  from  the  simplest 
questions  of  chemical  analysis,  to  the  more  recon- 
aite  problems.  Features  quite  as  commendable 
are  tne  regularity  and  .system  demanded  of  the 


student  in  the  performance  of  each  analysis. 
These  chaiacteristics  are  preserved  in  the  present 
edition,  which  we  can  heartily  recommend  as  asat- 
isfactory  guide  for  the  student  of  inorganic  chem- 
ical analysis. — New  York  Medical  Journal,  Oct.  9, 
1886 


RALFE,  CHARLES  H.,  M.  D.,  F.  R.  C.  P., 

Assistant  Physician  at  the  London  Hospital. 

Clinical  Chemistry.  In  one  pocket-size  12mo.  volume  of  314  pages,  with  16 
illustrations.     Limp  clotii,  red  edges,  $1.50.     See  StwkniK'  Serie.^  of  Manuals,  page  31. 

This  is  one  of  the  most  instructive  little  works  I  cine.  Dr.  Ralfe  is  thoroughly  acquainted  with  the 
that  we  have  met  with  in  a  long  time.  The  author  |  latest  contributions  to  his  science,  and  it  is  quite 
Is  a  physician  and  physiologist,  a.s  well  as  a  chem-  1  refreshing  to  find  the  subject  dealt  with  so  clearly 
ist,  consequently  the  book  is  unqualifiedly  prac-  I  and  simply,  yet  in  such  evident  harmony  with  the 
tlcal,  telling  the  physician  just  what  he  ought  to  |  modern  scientific  methods  and  spirit. — 3Iedi«al 
know,  of  the  applications  of  chemistry  in  medi-  \  Record,  February  2, 1884. 

CLASSED,  ALEXANHER, 

Professor  in  the  Royal  Polytechnic  School,  Aix-lorChnpeUe. 

Elementary  Quantitative  Analysis.  Translated,  with  notes  and  additions,  by 
Edgar  F.  Smith.  Pli.  I).,  Assistant  Professor  of  Chemistry  in  the  Towne  Scientific  School, 
University  of  Penna.     In  one  12mo.  volume  of  324  pages,  with  36  illus.     Cloth,  $2.00. 

It  is  probably  the  best  manual  of  an  elementary  and  then  advancing  to  the  analysis  of  minerals  and 
nature  extant,  insomuch  as  its  methods  are  the  such  products  as  are  met  with  in  applied  chemis- 
best.  It  teaches  by  examples,  commencing  with  try.  It  is  an  indispensable  book  for  students  in 
single   determinations,    followed  by  separations,    chemistry. — Boston  Journal  of  Chemistry,  Oct.  1878. 


Lea  Brothers  &  Co.'s  Publications — Pharm.,  Mat.  Med.,  Therap.  11 


BBVNTOW,  T,  LAUDEJR,  M.D.,  D.Sc,  F.M.S.,  F.M.C.I*,, 

Lectitrer  on  Materia  Medica  and  Therapeutics  at  St.  Bartholomew's  Hospital,  London,  etc. 

A  Text-book  of  Pharmacology,  Therapeutics  and  Materia  Medica; 

Including  the  Pharmacy,  the  Physiological  Action  and  the  Therapeutical  Uses  of  Drugs. 
Third   edition.     Octavo,  1305  pages,  230  illustrations.    Cloth,  ^5*50 ;  leather,  $6.50. 


No  words  of  praise  are  needed  for  this  work,  for 
it  has  already  spoken  for  itself  in  former  editions. 
It  was  by  unanimous  consent  placed  among  the 
foremost  books  on  the  subject  ever  published  in 
any  language,  and  the  better  it  is  known  and  studied 
the  more  highly  it  is  appreciated.  The  present 
edition  contains  much  new  matter,  the  insertion 
of  which  has  been  necessitated  by  the  advances 
made  in  various  directions  in  the  art  of  therapeu- 
tics, and  il  now  stands  unrivalled  in  its  thoroughly 
scientific  presentation  of  the  modes  of  drug  action. 
No  one  who  wishes  to  be  fully  up  to  the  times  in 
this  science  can  afford  to  neglect  the  stud.y  of  Dr. 
Brunton's  work.  The  indexes  are  excellent,  and 
add  not  a  little  to  the  practical  value  of  the  book. 
—Medical  Record,  May  25, 1889. 

Nothing  so  original  and  so  complete  on  the  action 
of  drugs  on  the  body  generally  and  on  its  various 


parts,  has  appeared  during  the  life  of  the  present 
generation.  This  is  strong  language,  but  it  is  the 
truth.  The  great  merit  of  this  work  is  that  tho 
author  has  been  able  so  well  to  coordinate  facts 
into  an  intelligible  and  rational  system  of  pharma- 
cology, and  henceforth  no  treatise  on  therapeutics 
will  be  considered  complete  which  does  not  in 
some  measure  adopt  this  method.  The  busy 
physician  will  approach  this  book  to  learn  some- 
thing that  will  better  fit  him  for  his  work,  and  on 
every  page  he  will  find  something  that  will  reward 
him  for  the  time  spent  in  its  perusal.  We  com- 
mend this  book  as  one  whien  every  physician 
should  own  and  study.  It  is  a  work  which  if  once 
owned  will  be  likely  to  be  read  and  consulted  till 
the  covers  fall  off  from  much  use. — Boston  Medical 
and  Surgical  Journal,  Dec.  20,  1888. 


HARB,  SOB  ART  A3IORY,  B.  Sc,  M.  D., 

Demonstrator  of  Th'rapeutics  and  Clinical  Professor  of  Diseases  of  Children  in  the  University  of 
Pennsylvania ;  Secretary  of  the  Convention  for  the  Bevision  of  the  United  States  Pharmacopceia  of 
1890. 

A  Text-Book  of  Practical  Therapeutics;  With  Especial  Reference  to  the 

Application  of  Remedial  Measures  to  Disease  and  their  Employment  upon  a  Rational 
Basis.  With  special  chapters  by  Drs.  G.  E.  de  Schweinitz,  Edward  Martin, 
J.  HowAED  Reeves  and  Barton  C.  Hirst.  In  one  handsome  octavo  volume  of  about 
700  pages.     Shortly. 

The  publishers  take  great  pleasure  in  announcing  the  early  appearance  of  a  new  work 
on  Therapeutics,  planned  on  lines  which  will  secure  for  it  a  leading  position  as  a  text-book 
and  work  of  reference.  The  author's  large  experience  in  experimental,  didactic  and 
clinical  work,  has  peculiarly  fitted  him  to  produce  a  volume  containing  all  that  is  latest 
and  best  in  the  application  of  remedial  measures,  and  to  present  this  material  in  a  way 
which  will  not  only  impress  it  into  the  mind  of  the  student  firmly,  because  rationally, 
but  which  will  also  render  it  of  daily  service  to  practitioners  by  reason  of  its  definite 
instructions  as  to  the  choice  of  various  agents  which  may  be  employed. 

MAISCH,  JOMJSrM.,  JPhar.  JX, 

Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  College  of  Pharmacy. 
A  Manual  of  Organic  Materia  Medica ;  Being  a  Guide  to  Materia  Medica  of 
the  Vegetable  and  Animal  Kingdoms.     For  the  use  of  Students,  Druggists,  Pharmacists 
and  Physicians.     New  f4th)  edition,  thoroughly  revised.    In  one  handsome  royal  12mo. 
volume  of  529  pages,  with  258  illustrations.     Cloth,  $3.     Just  ready. 


For  everyone  interested  in  materia  medica, 
Maiseh's  Blanual,  first  published  in  1882,  and  now 
in  its  fourth  edition,  is  an  indispensable  book. 
For  the  American  pharmaceutical  student  it  is 
the  work  which  will  give  him  the  necessary  knowl- 
edge in  the  easiest  way,  partly  because  the  text  is 
brief,  concise,  and  free  from  unnecessary  matter, 
and  partly  because  of  the  numerous  illustrations, 
which  bring  facts  worth  knowing  immediately  be- 


fore his  eyes.  That  it  answers  its  purposes  in  this 
respect  the  rapid  succession  of  editions  is  the  best 
evidence.  It  is  the  favorite  book  of  the  American 
student  even  outside  of  Maiseh's  several  hundred 
personal  students.  The  arrangement  of  its  con- 
tents shows  the  practical  tendency  of  the  book. 
Maiseh's  system  of  classification  is  easy  and  com- 
prehensive.— Pharmaceutische  Zeitung,  Germany, 
1890. 


rARRISM,  EDWARD, 

Late  Professor  of  the  Theory  and  Practice  of  Pharmacy  in  the  Philadelphia  College  of  Pharmacy. 

A  Treatise  on  Pharmacy :  designed  as  a  Text-book  for  the  Student,  and  as  a 
Guide  for  the  Physician  and  Pharmaceutist.  With  many  Formulae  and  Prescriptions. 
Fifth  edition,  thoroughly  revised,  by  Thomas  S.  Wiegand,  Ph.  G.  In  one  handsome 
octavo  volume  of  1093  pages,  with  256  illustrations.     Cloth,  $5 ;  leather,  $6. 

No  thorough-going  pharmacist  will  fail  to  possess  '  ods  of  combination  are  concerned,  can  afford  to 
himself  of  so  useful  a  guide  to  practice,  and  no  leave  this  work  out  of  the  list  of  their  works  of 
physician  who  properly  estimates  the  value  of  an  reference.  The  country  practitioner,  who  must 
accurate  knowledge  of  the  remedial  agents  em-  :  always  be  in  a  measure  his  own  pharmacist,  will 
ployed  by  him  in  daily  practice,  so  far  as  their  find  it  indispensable.— XouiswWe  Medical  News, 
miscibility,  compatibility  and  most  effective  meth-  |  March  29,  1884. 

HERMANN,  Dr.  L., 

Professor  of  Physiology  in  the  University  of  Zurich. 

Experimental  Pharmacology.  A  Handbook  of  Methods  for  Determining  the 
Physiological  Actions  of  Drugs.  Translated,  with  the  Author's  permission,  and_  with 
extensive  additions,  by  Robert  Meade  Smith,  M.  D.,  Demonstrator  of  Physiology  in  the 
University  of  Pennsylvania.      12mo.,  199    pages,  with  32  illustrations.     Cloth,  $1.50. 

STIZEE,  ALFRED,  M.  D,,  LL.  !>., 

Professor  of  Theory  and  Practice  of  Med.  and  of  Clinical  Med.  in  the  Univ.  of  Penna. 
Therapeutics  and  Materia  Medica.     A  Systematic  Treatise  on  the  Action  and 
Uses  of  Medicinal   Agents,  including  their   Description   and  History.  _  Fourth   edition, 
revised  and  enlarged.     In  two  large  and  handsome  octavo  volumes,  containing  1936  pages. 
Cloth,  $10.00;  leather,  $12.00. 


12        Lea  Brothers  &  Co.'s  Publications — Mat.  Med.,  Therap. 


8TILLB,  A,,  M,  D.,  Xi.  D.,  &  MAISCH,  J,  M,,  Phar,  I),, 

Professor  Emeritus  of  the  Theoryand  Prac-  Prof,  oj  Mat.  Med.  and  Botany  in  PhiUl. 

tice  of  Medicine  and  of  Clinical  Medicine  College  oJ Pharmacy, Sec'y  to  the  Amtri- 

in  the  University  of  Pennsylvania.  can  Pharmaceutical  Association, 

The  National  Dispensatory. 


CONTAINING  THE  NATURAL  HISTORY.  CHEMISTRY.  PHARMACY.  ACTIONS  AND    USES   OF 

MEDICINES.   INCLUDING  THOSE  RECOGNIZED  IN  THE  PHARMACOPCEIAS  OF  THE 

UN/TED  STATES.  GREAT  BRITAIN  AND  GERMANY,  WITH  NUMEROUS 

REFERENCES    TO  THE  FRENCH  CODEX. 

Fourth  edition  revised,  and  covering  the  new  British  Pharmacopoeia.  In  one  mag- 
nificent imperial  octavo  volume  of  1794  pages,  with  311  elaborate  engravings.  Price 
in  cloth,  $7.25  ;  leather,  raised  bands,  $8.00.  *:K.*This  work  will  be  fui~nished  with  Patent 
Ready  Reference  Thumb-letter  Index  for  $1.00  in  addition  to  the  price  in  any  style  of  binding. 
In  this  new  edition  of  The  National  Dispensatory,  all  important  changes  in  the 
recent  British  Pharmacopoeia  have  been  incorporated  throughout  the  volume,  while  in 
the  Addenda  will  be  found,  grouped  in  a  convenient  section  of  24  pages,  all  therapeutical 
novelties  which  have  been  established  in  professional  favor  since  the  publication  of  the 
third  edition  two  years  ago.  Since  its  first  publication.  The  National  Dispensatory 
has  been  the  most  accurate  work  of  its  kind,  and  in  this  edition,  as  always  before,  it  may 
be  said  to  be  the  representative  of  the  most  recent  state  of  American,  English,  German 
and  French  Pliarmacology,  Therapeutics  and  Materia  Medica. 

It  is  with  much  pleasure  t¥at  the  fourth  edition     discovery  have  received  due  attention.— A'ansa« 
of  this  magnificent  work  is  received.    The  authors     City  Medical  Index,  Nov.  1887. 

and  publishers  liave  reason  to  feel  proud  of  this,  We  think  it  a  matter  for  congratulation  that  the 
the  most  comprehensive,  elaborate  and  accurate  profession  of  medicine  and  that  of  pharmacy  have 
work  of  the  kind  ever  printed  in  this  country.  It  shown  such  aiipreciation  of  this  great  work  as  to  call 
is  no  wonder  that  it  has  become  the  standard  au-  for  four  editions  within  the  comparatively  briel 
thority  for  both  the  medical  and  pharmaceutical  period  of  eight  years.  The  matters  with  which  it 
profession,  and  that  four  editions  have  been  re-  deals  are  of  so  practical  a  nature  that  neither  the 
quired  to  supply  the  constant  and  increasing  physician  nor  the  pharmacist  can  do  without  the 
demand  since  its  first  appearance  in  1879.  The  latest  text-books  on  them.especially  those  that  are 
entire  field  has  been  gone  over  and  the  various  |  so  accurate  and  comprehensive  as  this  one.  The 
articles  revised  in  accordance  with  the  latest  j  book  is  in  every  way  creditable  both  to  the  authors 
developments  regarding  the  attributes  and  thera-  and  to  the  publishers.— A'eic  York  Medical  Journal, 
peutical  action  of  drugs.    The  remedies  of  recent  |  May  21, 1887. 


FABQVHABSON,  BOBJEMT,  M,  J).,  F.  B,  C,  P.,  ZL.  D., 

Lecturer  on  Materia  Medica  at  St.  Mary's  Hospital  Medical  School,  London. 

A  Guide  to  Therapeutics  and  Materia  Medica.  New  (fourth)  American, 
from  the  fourth  Englisli  edition.  Enlarged  and  adapted  to  the  U.  S.  Pharmacopoeia.  By 
Frank  Woodbury,  M.  D.,  Professor  of  Materia  Medica  and  Therapeutics  and  Clinical 
Medicine  in  the  Medico-Chirurgical  College  of  Philadelphia.  In  one  handsome  12mo. 
volume  of  581  pages.     Cloth,  $2.50. 

It  may  correctly  be  regarded  as  the  most  modern  actions  of  various  remedies  are  shown  in  p.irallel 
work  of  its  kind.  It  is  concise,  yet  complete,  columns.  This  aids  greatly  in  fixing  attention  and 
Containing  an  account  of  all  remedies  that  have  facilitates  study.  The  American  editor  has  en- 
a  place  in  the  British  and  United  States  Pharma  larged  the  work  so  as  to  make  it  include  all  the 
copoeias,  as  well  as  considering  all  non-official  but  remedies  and  preparations  in  the  U.  S.  Pharma- 
important  new  drugs,  it  become- in  fact  a  miniature  copoeia.  The  book  is  a  most  valuable  addition  to 
dispensatory.— Pnci/ic  Medical  Journal,  June,  18^9.     the  list  of  treatises  on  this  most  important  subject. 

An  especially  attractive  feature  is  an  arrange     — American  Practitioner  and  News,  ^ot.  9th,  1889. 
ment  by  which  the  physiological  and  therapeutical  , 


EBBS,  BOBEBT  T.,  M,  J)., 

Jackson  Professor  of  Clinical  Medicine  in  Harvard  University,  Medical  Department. 

A  Text-Book  of  Therapeutics  and  Materia  Medica.    Intended  for  the 
Use  of  Students  and  Practitionei-s.     Octavo,  544  pages.     Cloth,  $3.50  ;  leather,  $4.50. 

The  present  work  seems  destined  to  take  a  prom-  commend  the  book  and  congratulate  the  author 
inent  place  as  a  text-book  on  the  subjects  of  which  on  having  produced  so  good  a  one. — JV.  Y.  Medical 
It  treats.    It  possesses  all  the  essentials  which  we    Journal,  Keb.  18, 1888. 

expect  in  a  b<)ok  of  its  kind,  such  as  conciseness,  Dr.  Edes'  book  represents  better  than  any  older 
clearness,  a  judicious  classification,  and  a  reason-  book  the  practical  therapeutics  of  the  present 
able  degree  of  dogmatism.  All  the  newest  drugs  day.  The  book  is  a  thoroughly  practical  one.  The 
of  promise  are  treated  of.  The  clinical  index  at  classification  of  remedies  has  reference  to  their 
the  end  will  be  found  very  useful.    We  heartily    therapeutic  action.— PAarmaceu^icai  £ra,  Jan.  1888. 


BBUCB,  J,  MITCHELL,  M.  2>.,  F.  B.  C,  P., 

Physician  and  Lecturer  on  Materia  Medica  and  Therapeutics  at  Charing  Cross  Hospital,  London. 
Materia  Medica  and  Therapeutics.     An  Introduction  to  Rational  Treatment. 
Fourth  edition.    r2mo.,  591  pages.   Cloth,  $1.50.     See  Students' Series  of  Manuals,  i^age  31. 

GBIFFITH,  BOBEBT  EGLESFIELD,  M,  jD. 

A  Universal  Formulary,  containing  the  Methods  of  Preparing  and  Adminis- 
tering Officinal  and  other  Medicines.  The  whole  adapted  to  Physicians  and  Pharmaceut- 
ists. Third  edition,  thoroughly  revised,  with  numerous  atlditions,  by  John  M.  Maisch, 
Phar.  D.,  Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  College  of  Pharmacy. 
In  one  octavo  volume  of  775  p.ige-s,  with  38  illustrations      Cloth,  $4.50;  leather,  $5.50. 


Lea  Brothers  &  Co.'s  Publications — Pathol.,  Histol.  13 

Lecturer  on  Pathology  and  Jlorbid  Anatomy  at  Charing-Cross  Hospital  Medical  School,  London,- 
Pathology  and  Morbid  Anatomy.  Xew  (sixth)  American  from  the  seventli^ 
revised  English  edition.  Octavo,  539  pp.,  with  167  engravings.  Cloth,  §2.75.  Just  ready. 
The  Pathology  and  Morbid  Anatomy  of  Dr.  translated  into  English,  are  too  abstruse  for  the 
Green  is  too  well  known  by  members  of  the  medi-  physician.  Dr.  Green's  work  precisely  meets  his 
cal  profession  to  need  any  commendation.  There  wishes.  The  cuts  exhibit  the  appearances  of 
is  scarcely  an  intelligent  physician  anywhere  who  pathological  structures  just  as  they  are  seen 
has  not  the  work  in  his  library,  for  it  is  almost  an  through  the  microscope.  The  fact  that  it  is  so 
essential.  In  fact  it  is  better  adapted  to  the  wants  generally  employed  as  a  text-book  by  medical  stu- 
of  general  practitioners  than  any  work  cf  the  kind  dents  is  evidence  that  we  have  not  spoken  too 
with  which  we  are  acquainted.  The  works  of  '  much  in  its  favor.— Cincinnati  Medical  Aews,  Oct. 
German  authors  upon  pathology,  which  have  been  ;  1889. 

:payne,  josejps  f.,  m.  d.,  f,  r,  a  p.. 

Senior  Assistant  Physician  and  Lecturer  on  Pathological  Anatomy,  St.  Thomas'  Hospital,  London, 
A  Manual  of  General  Pathology.  Designed  as  an  Introduction  to  the  Prac- 
tice of  Medicine.  Octavo  of  524  pages,  with  152  illus.  and  a  colored  plate.  Cloth,  $3.50. 
Knowing,  as  a  teacher  and  examiner,  the  exact  eal  factors  in  those  diseases  now  with  reasonable 
needs  of  medical  students,  the  author  has  in  the  certainty  ascribed  to  pathogenetic  microbes.  In 
work  before  us  prepared  for  their  especial  use  this  department  he  has  been  very  full  and  explicit, - 
what  we  do  not  hesitate  to  say  is  the  best  introdue-  not  only  in  a  descriptive  manner,  but  in  the  tech- 
tion  to  general  pathology  that  we  have  yet  ex-  nique  of  investigation.  The  Appendix,  giving 
amined.  A  departure  which  our  author  has  methods  of  research,  is  alone  worth  the  price  of  the 
taken  is  the  greater  attention  paid  to  the  causa-  book,  several  times  over,  to  every  student  of  ^ 
tion  of  disease,  and  more  especially  to  the  etiologi-    pathology. — St.  Louis  Med.  and  Surg,  /our.,  Jetn. '89^- 

SFNW,  NICHOLAS,  M.J).,  JPh.D., 

Professor  of  Principles  of  Surgery  and  Surgical  Pathology  in  Bush  Medical  College,  Chicago. 

Surgical  Bacteriology.     Inone  handsome  octavo  of  259  pages,  with  13  plates, 
of  which  9  are  colored.     Cloth,  $1.75. 

COATS,  JOSEFS,  M.  D.,  F.  F,  JP.  S., 

Pathologist  to  the  Glasgow  Western  Infirmary. 
A  Treatise  on  Pathology.     In  one  very  handsome  octavo  volume  of  829  pages, 
with  339  beautiful  illustrations.     Cloth,  $5.50 ;  leather,  $6.50. 

Medical  students  as  well  as  physicians,  who  manner,  the  changes  from  a  normal  condition 
desire  a  work  for  study  or  reference,  that  treats  effected  in  structures  by  disease,  and  points  out 
the  subjects  in  the  various  departments  in  a  very  the  characteristics  of  various  morbid  agencies, 
thorough  manner,  but  without  prolixity,  will  cer-  so  that  they  can  be  easily  recognized.  But,  not 
tainly  give  this  one  the  preference  to  any  with  limited  to  morbid  anatomy,  it  explains  fully  ho'w 
which  we  are  acquainted.  It  sets  forth  the  most  the  functions  of  organs  are  disturbed  by  abnormal 
recent    discoveries,  exhibits,    in  an    interesting    conditions. —  Cincinnati  Medical  News,  Oct.  18S3. 

WOOnHEAJy,  G.  SIMS,  M.  n.,  F.  B.  C.  F.  E., 

Demonstrator  of  Pathology  in  the  University  of  Edinburgh. 
Practical  Pathology.     A  Manual  for  Students  and  Practitioners.     In  one  beau- 
tifal  octavo  volume  of  497  pages,  with  136  exquisitely  colored  illustrations.     Cloth,  $6.00. 

It  forms  a  real  guide  for  the  student  and  practi-  ■  themselves  with  this  manual.  The  numerous 
tioner  who  is  thoroughly  in  earnest  in  his  en-  drawings  are  not  fancied  pictures,  or  merely 
deavor  to  see  for  himself  and  do  for  himself.  To  schematic  diagrams,  but  they  represent  faithfully 
the  laboratory  student  it  will  be  a  helpful  com-  the  actual  images  seen  under  the  microscope. 
panion,  and  all  those  who  may  wish  to  familiarize  The  author  merits  all  praise  for  having  produced 
themselves  with  modem  methods  of  examining  a  valuable  work. — Medical  Record,  May  31, 1884. 
morbid  tissues   are   strongly  urged    to    provide 

SCHAFEB,  EDWABD  A.,  F.  B,  S., 

Jodrell  Professor  of  Physiology  in  University  College,  London, 
The  Essentials  of  Histology.      In  one  octavo  volume  of  246  pages,  with 
281  illustrations.     Cloth,  $2.25. 

This  admirable  work  was  greatly  needed.  It  cially  adapted  for  laboratory  work,  at  the  same 
has  been  written  with  the  object  of  supplying  time  it  is  Intended  to  serve  as  an  elementary 
the  student  with  directions  for  the  microscopical  text-book  of  histology,  comprising  all  the  essen- 
examination  of  the  tissues,  which  are  given  in  a  tial  facts  of  the  science.— T/ie  Physician  and  Sur- 
clear  and  understandable  way.     Although  espe-  ,  geon,  July,  1887. 


KLEIN,  E.,  M.  D.,  F.  B.  S., 

Joint  Lecturer  on  General  Anat.  and  Phys.  in  the  Med.  School  of  St.  Bartholomew's  Hosp.,  London. 
Elements  of  Histology.     Fourth  edition.     In  one  12mo.  volume  of  376  pages, 
with  194  illus.    Limp  cloth,  $1.75.      See  Students'  Series  of  Manuals,  page  31. 

Considered  with  regard  to  its  contents,  it  can    index  affords  a  ready  reference  to  the  histology  ol 
only  be  looked  on  as  a  large  and  comprehensive    every  tissue  and  organ,  and  presents,  at  the  same 
volume.    Kew  and  original  illustrations  have  been    time,  a  complete  glossary  of  the  scientific  terms.— 
added,  with  the  help  of  which  the  structureof  each    Provincial  Medical  Journal,  May  1, 18S9. 
tissue'  becomes  clear  to  the  reader.    A  copious 


FEFFEB,  A.  J.,  M.  B.,  M.  S.,  F.  B,  C.  S,, 

Surgeon  and  Lecturer  at  St.  Mary's  Hospital,  London. 

Surgical  Pathology.     In  one  pocket-size  12mo.  volume  of  511  pages,  with  81 

illustrations.  Limp  cloth,  red  edges,  $2.00.     See  Students' Series  of  Manuals,  ^&ge  31. 

Its  form  is  practical,  its  language  is  clear,  and  I  in  it  nothing  that  is  unnecessary.  The  list  o  1 
the  information  set  forth  is  ^ell-arranged  well-  subject^  covers  the  whole  range  of  surgery.- JTe^ 
indexed  and  well-illustrated.  The  student  will  find  |  Yo-rk  Medical  Journal,  May  31, 1884. 


1-i  Lea  Brothers  &  Co.'s  Publications — Practice  of  Med. 

JFLINT,  AUSTIN,  M.  D.,  Li.  J>. 

Prof,  of  the  Priuciple-s  nnd  Practice  nf  ifed.  and  of  Ctvx.  Mtd.  in  BeHevtiC  Hospital  Medical  College,  N.  7. 

A  Treatise  on  the  Principles  and  Practice  of  Medicine.    Designed  for 

the  use  of  Students  and  Practitioners  of  Medicine.  New  (sixth)  edition,  thoroughly  re- 
vised and  rewritten  !>>•  tlie  Author,  a.ssistcd  !>}•  William  H.  Welch,  M.  D.,  Professor  of 
Pathology,  Johns  Hopkins  University,  Baltimore,  and  Austin  Klint,  Jr.,  M.  D.,  LL.  D., 
Professor  of  Physiology,  Bellevue  Hospital  Medical  College,  N.  Y.  In  one  very  handsome 
octavo  volume  of  1160  pages,  with  illustrations.    Cloth,  $5.o0;  leather,  $6.50. 

A  new  edition  of  a  work  of  such  esJtablished  rep-  '  general  approval  by  medical  students>  and  practl- 
otationa.-  Flint's  Medicine  needs  but  few  word.sto  tioners  as  the  work  of  Profes.«or  Flint.  In  all  the 
commend  it  to  notice.  It  may  in  truth  be  .said  to  medical  college.i  of  the  United  States  it  is  the  fa- 
embodv  the  fruit  of  his  labors  in  clinical  medicine,  vorite  work  upon  Practice;  and,  as  we  have  stated 
ripeneii  by  the  experience  of  a  long  life  devoted  to  before  in  alluding  to  it,  there  is  no  other  medical 
itB  pursuit,  .\merioa  may  well  be  proud  of  having  work  that  can  be  so  generally  found  in  the  libra- 
produced  a  man  whoso  indefatigable  indu.-try  and  ries  of  physicians.  In  every  state  and  territory 
gifts  of  genius  have  done  so  much  to  advance  med-  of  this  vast  country  the  book  that  will  be  most  likely 
cine;  ami  all  English-reading  students  must  be  to  be  found  in  the  office  of  a  medical  man,  whether 
grateful  tor  the  work  which  he  has  left  behind  him.  iu  city,  town,  village,  or  at  some  cross-roads,  is 
It  has  few  equals,  either  in  point  of  literary  excel-  Flint's  Practice.  We  make  this  statement  to  a 
lence,  or  of  scientific  learning,  and  no  one  can  considerable  extent  from  personal  observation,  and 
etudy  its  pages  without  being  struck  by  the  Iu-  it  is  the  testimony  also  of  others.  An  examina- 
cidity  and  accuracy  which  characterize  them.  It  tion  shows  that  very  considerable  changes  have 
is  qualities  such  as  these  which  render  it  so  valu-  been  made  in  the  sixth  edition.  The  work  may  un- 
.abl"  ffT  its  purpose,  and  give  it  a  foremost  place  doubtedly  be  regarded  as  fairly  representing  the 
among  the  text-books  of  this  generation. —  The  present  state  of  the  science  of  medicine,  and  as 
London  Lancet,  March  12,  1SS7.  reflecting  the  views  of  those  who  exemplify  in 
f  No  text-book  on  the  principles  and  practice  of  their  practice  the  present  stage  of  progress  of  med- 
medicine  has  ever  met  in  this  country  with  such  |  leal  t^.— Cincinnati  Medical  yewt,  Oct.  1886. 


HARTSHORNB,  HENRY,  31,  X).,  LL,  X>., 

Lately  Professor  of  Hygiene  in  the  University  of  Pennsyh-ania. 

Essentials  of  the  Principles  and  Practice  of  Medicine.  A  Handbook 
for  Stiulents  and  Practitioners.  Fifth  edition,  thoroughly  revised  and  rewritten.  In  one 
royal  12mo.  volume  of  669  pages,  with  144  illustrations.     Cloth,  $2-.75;  half  bound,  $3.00. 

■   Within  the  compass  of  600  nages  it  treats  of  the  this  one;  and  probably  not  one  writer  in  our  day 

history  of  medicine,  general  pathology,  general  had  a  better  opportunity  than  Dr.  Hartshorne  for 

symptomatology, and  physical  diagnosis  (including  condensing  all  the  views  of  eminent  practitioners 

laryngoscope,  ophthalmoscope,  etc.),  general  ther-  into  a  12mo.    The  numerous  illustrations  will  be 

apeutics,  nosology,  and  special  pathology  and  prac-  very  useful  to  students  especially.    These  essen- 

tice.    There  is  a  wonderful  amount  of  information  tials,  as  the  name  suggests,  are  not  intended  to 

contained  in  this  work,  and  it  is  one  of  the  best  supersede  the  text-books  of  Flint  and  Bartholow, 

«f  its  kind  that  we  have  seen. — Olasgow  Medical  but  they  are  the  most  valuable  in  affording  the 

Journal,  Nov.  1882.  means  to  see  at  a  glance  the  whole  literature  of  any 

An  indispensable  book.    No  work  ever  exhibited  disease,  and  the  most  valuable  treatment.— CAiVago 
a  better  average  of  actual  practical  treatment  than  ,  Medical  Journal  and  Ej:amin€r,  April,  1882. 


REYNOLDS,  J,  RUSSELL,  31,  !>., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  University  College,  London. 
A  System  of  Medicine.  With  notes  and  additions  by  Henry  Hartshorne, 
A.  M.,  M.  D.,  late  Professor  cf  Hygiene  in  the  University  of  Pennsylvania.  In  three  large 
and  handsome  octavo  volumes,  containing  3056  double-columned  pages,  with  317  iliualra- 
tions.  Price  per  volume,  cloth,  $5.00 ;  sheep,  $6.00 ;  very  handsome  half  Russia,  raised  bands, 
$6.50.     Per  set,  cloth,  $15;  leather,  $18.     Sold  only  by  subscription. 

Really  too  much  praise  can  scarcely  be  given  to    of  reference  it  is  invaluable.     It  is  up  with  the 
this  noble  book.     It  is  a  cyclopaedia  of  medicine    times.    It  is  clear  and  concentrated  in  style,  and 
written  by  some  of  the  best  men  of  Europe.    It  is    its    form  is  worthy  of   its    famous    publisher. — 
full  of  useful  information,  such  as  one  finds  fre-    LouisvuU  Medical  News,  Jan.  31, 1880. 
quent  need  of  in  one's  daily  work.    As  a  book 


81ILLE,  ALFRED,  31,  D,,  LL,  I),, 

Professor  Emeritus  of  the  Theory  and  Practice  of  Med.  and  of  Clinical  Med.  in  the  Univ.  of  Penna. 
Cholera:    Its  Origin,  History, Causation, Symptoms,  Lesions,  Prevention  and  Treat- 
ment. In  one  handsome  12mo.  volume  of  163  pages,  with  a  chart.  Cloth,  $1.25. 


WATSON,  SIR  THOMAS,  31.  D., 

Late  Physician  in  Ordinary  to  the  Queen. 

Lectures  on  the  Principles  and  Practice  of  Physic.  A  new  American 
from  the  fifth  English  edition.  Edited,  with  addition;?,  and  190  illustrations,  by  Henkt 
Hartshorne,  A.  M.,  M.  D.,  late  Profe.s.sor  of  Hvgiene  in  the  Universitvof  Pennsylvania. 
In  two  large  octavo  volumes  of  1840  pages.     Cloth,  $9.00  ;  leather,  $11.00. 


LECTURES  ON  THE  STUDY  OF  FEVER.    By  BRISTOWE'S    PRACTICE  OF  MEDICINE.     la 

A.  HcDsos,  M.   D.,  M.   R.   I.  A.    In  one  octavo  o°«  octavo  volume, 

volume  of  308  pages.     Cloth  r' 50  LA  ROCHE  ON  YELLOW  FEVER,  considered  in 

^  r^'PYn  ^ol  rv^v^ofofit^Tlo^h^^^^^'  ^e^^^^'Ki:!!^'^.^^^.^ 

K.  C.  C.     In  one  8vo.  vol.  of  354  pp.    Cloth.  $2.25  ^^j^^  ^^avo  volumes  of  1468  pp.    ClSth.  87.00. 


Lea  Brothers  &  Co.'s  Publications — System  of  Med.  15 

For  Sale  by  Subscription  Only. 


A  System  of  Practical  Medicine. 

BY  AMERICAN  AUTHORS. 

Edited  by  WILLIAM   PEPPER,  M.  D.,  LL.  D., 

PROVOST  AND  PBOFESSOR  OF  THE  THEORY  AND  PRACTICE  OF  MEDICINE  AND  OF 
CUNICAL  MEDICINE  IN  THE  TJNIVEKSITY  OF  PENNSYX.VANIA, 

Assisted  by  Lotns  Stare,  M.  D.,  Clinical  Professor  of  the  Diseases  of  Children  in  the 
Hospital  of  the  University  of  Pennsylvania. 

The  complete  work,  in  five  volumes,  containing  5573  pages,  with  198  illustrations,  is  now  ready. 
Price  per  volume,  cloth,  $5;  leather,  ?6  ;  half  Russia,  raised  bounds  and  open  back,  $7. 


In  this  great  work  American  medicine  is  for  the  first  time  reflected  by  its  worthiest 
teachers,  and  presented  in  the  fall  development  of  the  practical  utility  which  is  its  pre- 
eminent characteristic.  The  most  able  men — from  the  East  and  the  West,  from  the 
North  and  the  South,  from  all  the  prominent  centres  of  education,  and  from  all  the 
hospitals  which  afford  special  opportunities  for  study  and  practice — have  united]  in 
generous  rivalry  to  bring  together  this  vast  aggregate  of  specialized  experience.         -'  .^^ 

The  distinguished  editor  has  so  ■apportioned  the  work  that  to  each  author  has  been 
assigned  the  subject  which  he  is  peculiarly  fitted  to  discuss,  and  in  which  his  views 
will  be  accepted  as  the  latest  expression  of  scientific  and  practical  knowledge.  The-, 
practitioner  will  therefore  find  these  volumes  a  complete,  authoritative  and  unfailing  work  : 
of  reference,  to  which  he  may  at  all  times  turn  with  full  certainty  of  finding  what  he  needs 
in  its  most  recent  aspect,  whether  he  seeks  information  on  the  general  principles  of  medi- 
cine, or  minute  guidance  in  the  treatment  of  special  disease.  So  wide  is  the  scope  of  the- 
work  that,  with  the  exception  of  midwifery  and  matters  strictly  surgical,  it  embraces  the 
whole  domain  of  medicine,  including  the  departments  for  which  the  physician  is  accustomed 
to  rely  on  special  treatises,  such  as  diseases  of  women  and  children,  of  the  genito-urinary 
organs,  of  the  skin,  of  the  nerves,  hygiene  and  sanitary  science,  and  medical  ophthalmology 
and  otology.  Moreover,  authors  have  inserted  the  formulas  which  they  have  found  mosl 
efficient  in  the  treatment  of  the  various  affections.  It  may  thus  be  truly  regarded  as  a 
Complete  Library  of  Practical  Medicine,  and  the  general  practitioner  possessing  it 
may  feel  secure  that  he  will  require  little  else  in  the  daily  round  of  professional  duties. 

In  spite  of  every  effort  to  condense  the  vast  amount  of  practical  information  fur- 
nished, it  has  been  impossible  to  present  it  in  less  than  5  large  octavo  volumes,  containing 
about  5600  beautifully  printed  pages,  and  embodying  the  matter  of  about  15  ordinary; 
octavos.     Illustrations  are  introduced  wherever  requisite  to  elucidate  the  text. 

A  detailed  prospectus  will  be  sent  to  any   address  on  application  to  the  pyhlishers". 

These  two  volumes  bring  this  admirable  work  ;  physicians  who  are  acquainted  with  all  the  varie- 
to  a  close,  and  fully  sustain  the  high  standard  ;  ties  of  climate  in  the  United  States,  the  character 
reached  by  the  earlier  volumes ;  we  have  only  of  the  soil,  the  manners  and  customs  of  the  peo 
therefore  to  echo  the  eulogium  pronounced  upon  pie,  etc.,  it  is  peculiarly  adapted  to  the  wants 
them.  We  would  warmly  congratulate  the  editor  ,  of  American  practitioners  of  medicine,  and  it 
and  his  collaborators  at  the  conclusion  of  their  \  seems  to  us  that  every  one  of  them  would  desire 
laborious  task  on  the  admirable  manner  in  which,  to  have  it.  It  has  been  truly  called  a  "Complete 
from  first  to  last,  they  have  performed  their  several  Library  of  Practical  Medicine,"  and  the  general 
duties.  They  have  succeeded  in  producing  a  ;  practitioner  will  require  little  else  in  his  round 
work  which  will  long  remain  a  standard  work  of  of  professional  duties. — Cincinnati  Medical  News, 
reference,  to  which  practitioners  will    look    for  |  March,  1886. 

guidance,  and  authors  will  resort  for  facts.  '  Each  of  the  volumes  is  provided  with  a  most 
From  a  literary  point  of  view,  the  work  is  without  copious  index,  and  the  work  altogether  promises 
any  serious  blemish,  and  in  respect  of  production,  to  be  one  which  will  add  much  to  the  medical 
it  has  the  beautiful  finish  that  Americans  always  literature  of  the  present  centurv,  and  reflect  great 
give  their  works. — Edvnburgh  Medical  Journal,  Jan.  '  credit  upon  the  scholarship  and  practical  acumen 
1887.  j  of  its  authors.— 77i6  London  Lancet,  Oct.  3,  1885. 

*  *  ThegreateatdistinctivelyAmerican  work  on  I  The  feeling  of  proud  satisfaction  with  which  the 
the  practice  of  medicine,  and,  indeed,  the  super-  American  profession  sees  this,  its  representative 
lative  adjective  would  not  be  inappropriate  were  system  of  practical  medicine  issued  to  the  medi- 
even  all  other  productions  placed  in  comparison.  '  cal  world,  is  fully  justified  by  the  character  of  the 
An  examination  of  the  five  volumes  is  sufficient  work.  The  entire  caste  of  the  system  is  in  keep- 
to  convince  one  of  the  magnitude  of  the  enter-  ing  with  the  best  thoughts  of  the  leaders  and  fol- 
prise,  and  of  the  success  which  has  attended  its  lowers  of  our  home  school  of  medicine,  and  the 
fulfilment.— T/ie  Medical  Age,  July  26, 1886.  ■  combination  of  the  scientific  study  of  disease  and 

This  huge  volume  forms  a  fitting  close  to  the    the  practical  application  of  exact  and  experimen- 

freat  system  of  medicine  which  in  so  short  a  time  tal  knowledge  to  the  treatment  of  human  mal- 
as  won  so  high  a  place  in  medical  literatuie,  and  adies,  makes  every  one  of  us  share  in  the  pride 
has  done  such  credit  to  the  profession  in  this  that  has  welcomed  Dr.  Pepper's  labors.  Sheared 
country.  Among  the  twenty-three  contributors  '  of  the  prolixity  that  wearies  the  readers  of  the 
are  the  names  of  the  leading  neurologists  in  German  school,  the  articles  glean  these  same 
America,  and  most  of  the  work  in  the  volume  is  of    fields  for  all  that  is  valuable.     It  is  the  outcome 


the  highest  order. — Boston  Medical  and  Surgical 
Journal,  July  21, 1887. 
We  consider  it  one  of  the  grandest  work 


of  American  br.ains,  and  is  marked  throughout 
by  rtiuch  of  the  sturdy  independence  of  thought 
and  originality  that  is  a  national  characteristic. 


Practical  Medicine  in  the  English  language.  It  is  j  Yet  nowhere  is  there  lack  of  study  of  the  mo8t 
a  work  of  which  the  profession  of  this  country  can  ,  advanced  views  of  the  d&j.— North  Carolina  Medi- 
f^el    proud.     Written    exclusively  by  American  |  cal  Journal,  Sept.  1886. 


16 


Lea  Brothers  &  Co.'s  Publications — Clinical  Med.,  etc. 


JFOTHEBGILL,  J.  M.,  M.  !>.,  Edin,,  M,  R.  C,  J*.,  Zand., 

PhvHinan  to  the  City  of  Londoii  Hospital  for  Disense^  of  the  Chest. 

The  Practitioner's  Handbook  of  Treatment ;  Or,  The  Principles  of  Tliera- 

peutics.   New  (tliinl)  edition.    In  one  8vo.  vol.  ol' 6(j]  pages.    Clotli,  J!3.75 ;  leather,  $4.75, 

To  have  a  description  of  the  normal  pliy.siologi-  |      Tliis  is  a  wonderful  book.    If  there  be  such  a 

cal  processes  of  an  organ  and  of  the  methods  of    thing  as  "medicine  made  easy,"  this  is  the  work  to 

treatment    of     its     morbid     conditions     brought    accomplish  this  result.— fn.  3/crf.  3/on//i.,  June,'87 


of  its  morbid  condition.' 
together  in  a  single  chapter,  and  the  relations 
between  tlie  two  clearly  slated,  cannot  fail  to  prove 
•  great  convenience  to  many  thoughtful  but  busy 
physicians.  The  practical  value  of  the  volume  is 
greatly  increased    by  the  introduction  of  many 

Firescfiptions.  That  the  orofession  appreciates 
hat  the  author  hasundertalven  an  important  work 
and  has  accomplislied  it  is  shown  by  the  demand 
f  or  this  third  edition.— A'.  }'.  Med.  Jour.,  June  11,'87. 


h  this  result. 

It  isan  excellent,  practical  work  on  therapeutics, 
well  arranged  and  clearly  expressed,  useful  to  the 
student  and  young  practitioner,  perhaps  even  to 
the  old. — Dublin  Juujiial  of  Meiiical  Science,  March, 
1888. 

We  do  not  know  a  more  readable,  practical  and 
useful  work  on  the  treatment  of  disease  than  the 
one  we  have  now  before  us.— Pticijic  Medical  and 
Surgical  Journal,  October,  1887. 


VAVGHAN,  VICTOR  C.,JPIi.D.,  31,  D., 

Prof,  of  Phys.  and  Path.  Chan,  ami  Assoc.  Prof,  of  Therap.  and  Mat.  Med.  in  the  Univ.  of  Mieh. 

and  NOT1l\  FREDERICK  G.,  M.  D. 

Instructor  in  JJiigiine  and  Phi/s.  Chcm.  in  the  Univ.  of  Mich. 

Ptomaines  and  Leucomaines,  or  Putrefactive  and  Physiological 
Alkaloids.     In  one  handsome  12mo.  volume  of  311  pages.     Just  ready.     Cloth,  $1.75. 

This  book  is  what  has  been  wanted  for  some  observers  and  experimenters  on  micro-organisms, 

year.--  by  the  medical  profession.    The  subject  of  and  to  trace  the  relationship  of  cause  and  effect 

ptomaines  and  leucomaines,  so  far  as  their  disease-  of  the  putrefactive  alkaloids.      We  congratulate 

producing  relations  are  concerned,  has  been  under  the  autriors  upon  the  successful  presentation  of 

special  study  scarcely  more  than   a  decade,   but  the  current  views  on  the  subject  in  such  manner 

within  that  period  facts  have   been    discovered  as  to  make  them  easily  comprehensible,  while  to 

upon  which  theories  of  permanent  standing  have  the  practitioner,  after  he  lias  carefully  read  the 

been  built,  until  now  the  practitioner  is  far  be-  book,  it  will  serve,  also,  as  a  frequent  reference 

hind    the  times  if   he  does  not  appreciate   the  work,becauseof  the  technical  information  it  gives, 

importance  of  ptomaines.    This  is  the  tirst  attempt  Va.  Medical  Monthly,  Sept.  1888. 
tnade  to  collect   into  book  form  the  results  of 

EINLAYSONf  JA3IES,  M.  !>.,  Editor , 

Phystetan  and  Lecturer  on  Clinical  Medicine  in  the  Glasgow  Western  Infirmary,  etc. 

Clinical  Manual  for  the  Study  of  Medical  Cases.  With  Chapters 
by  Prof.  Gairdner  on  the  Physiognomy  of  Disease;  Prof.  Stephenson  on  Diseases  of 
the  Female  Organs;  Dr.  Robertson  on  Insanity;  Dr.  Gemmell  on  Physical  Diagnosis; 
Dr.  Coats  on  Laryngoscopy  and  Post-Mortem  Examinations,  and  by  the  Editor  on  Case- 
taking,  Family  History  and  Symptoms  of  Disorder  in  the  Various  Systems.  New  edition. 
In  one  12mo.  volume  of  682   pages,  with   158  illustrations.    Cloth,  $2.50. 

The  profession  cannot  but  welcome  the  second  I  treatise  on  medical  diagnosis,  in  which  every  sign 
edition  of  this  very  valuable  work  of  Finlayson 
and  his  collaborators.  The  eize  of  the  book  has 
been  increased  and  the  number  of  illustrations 
nearly  doubled.  The  manner  in  which  the  subject 
is  treated  is  a  most  practical  one.  Symptoms 
alone  and  their  diagnostic  indications  form  the 
basis  of  discussion.  The  text  explains  clearly  and 
fully  the  methods  of  examinations  and  the  con- 
clusions to  be  drawn  from  the  physical  signs.— 
The  Medical  News,  April  2.3,  1887. 

We  are  pleased  to  see  a  second  edition  of  this 
admirable    book.     It   is   essentially   a   practical 


and  symptom  of  disease  is  carefully  analj'zed,  and 
their  relative  significance  in  the  different  affec- 
tions in  which  they  occur  pointed  out.  From  their 
.synthesis  the  student  can  accurately  determine 
the  disease  with  which  he  has  to  deal.  The  book 
has  no  competitor,  nor  is  it  likely  to  have  as  long 
as  future  editions  maintain  its  present  standard  of 
excellence.  The  general  practitioner  will  find 
many  practical  hints  in  its  pages,  while  a  careful 
study  of  the  work  will  save  liim  from  many  pitfalls 
in  diagnosis. — Liverpool  Medico- Chirurgical  Jour- 
nal, January,  1887. 


FENWICK,  SAMUEL,  31.  X>., 

Assistant  Physician  to  the  London  Hospital. 

The  Student's  Guide  to  Medical  Diagnosis.  From  the  third  revised  and 
enlarged  English  edition.  In  one  very  handsome  royal  12mo.  volume  of  328  pages,  with 
87  illustrations  on  wood.     Cloth,  $2.25. 

HABERSHON,  S.  O.,  31,  !>., 

Senior  Physician  to  and  late  Led.  on  Principles  and  Practice  of  Med.  at  Ouy's  Hospital,  London. 

On  the  IDiseases  of  the  Abdomen ;  Comprising  those  of  the  Stomach,  and 
other  parts  of  the  Alimentary  Canal,  CEsoj^hagus,  Caecum,  Intestines  and  Peritoneum.  Second 
American  from  third  enlarged  and  revised  English  edition.  In  one  handsome  octavo 
volume  of  554  pages,  with  illustrations.     Cloth,  $3.50. 

This  valuable  treatise  on  diseases  of  the  stomach  to  the  times,  and  making  it  a  volume  of  interest  to 
and  abdomen  will  be  found  a  cycloptedia  of  infor-  the  practitioner  in  every  field  of  medicine  and 
tnation,  systematically  arranged,  on  all  diseases  of  surgery.  Perverted  nutrition  is  in  some  form 
the  alimentary  tract,  from  the  mouth  to  the  associated  with  all  diseases  we  have  to  combat, 
rectum.  A  fair  proportion  of  each  chapter  is  and  we  need  all  the  light  that  can  be  obtained  on 
devoted  to  symptoms,  pathology,  and  ther.ipeutics.  ,  a  subject  so  bread  and  general.  Dr.  Habershon's 
Tne  present  edition  is  fuller  than  former  ones  in  i  work  is  one  that  every  practitioner  should  read 
many  particulars,  and  has  been  thoroughly  revised  '  and  study  for  himself.— i\'.  Y.  Medical  Journal, 
and  amended  bj'  the  author.  Several  new  chap-  ;  April,  1879. 
ers  have  been  added,  bringing  the  work  fully  up  ' 

TAJn^ER,  TH03IAS  HAWKES,  31,  D, 

A  Manual  of  Clinical  Medicine  and  Physical  Diagnosis.  Third  American 
rom  the  second  London  edition.  Revised  and  enlarged  by  Tilbury  Fox,  M.  D. 
In  one  small  12mo,  volume  of  362  pages,  with  illustrations.     Cloth,  $1,50. 


Lea  Brothers  &  Co.'s  Publications — Hygiene,  Electr.,  Pract.        17 


BARTHOLOW,  MOBEMTS,  A.  M.,  M.  D.,  LL,  J>., 

Prof,  of  Materia  Medica  and  General  Therapeutics  in  the  Jefferson  Med.  Coll.  of  Phila.,  etc. 
Medical  Electricity.     A  Practical  Treatise  on  the  Applications  of  Electricity 
to  Medicine  and  Surgery.     JSTew  (third)  edition.    In  one  very  handsome  octavo  volume  of 
308  pages,  with  110  illustrations.     Cloth,  §2.50. 

The  fact  that  this  work  has  reached  its  third  edi- 
tion in  six  years,  and  that  it  has  been  kept  fuUy 
abreast  with  the  increasing  use  and  knowledge  of 


electricity,demonstrates  its  claim  to  be  considered 
a  practical  treatise  of  tried  value  to  the  profession. 
Trie  matter  added  to  the  present  edition  embraces 
the  most  recent  advances  in  electrical  treatment. 
The  illustrations  are  abundant  and  clear,  and  the 
work  constitutes  a  fall,  clear  and  concise  manual 
well  adapted  to  the  needs  of  both  student  and 
practitioner. —  The  Medical  JS'eics,  May  1-1,  1887. 

This  "practical  treatise  on  the  applications  of 
«lectricity  to  medicine  and  surgery"  has  grown  to 
be  so  important  a  work  that  every  practitioner 


should  read  it,  especially  when  it  is  recalled  what 
possibilities  lie  in  the  path  of  the  further  study  of 
the  therapeutics  of  electricity.  Dr.  Bartholow  has 
here  presented  the  profession  with  a  concise  work 
that,  beginning  with  elementary  descriptions  and 
principles,  gradually  grows,  page  by  page,  into  a 
magnificently  practical  treatise,  describing  opera- 
tions in  detaii,  and  giving  records  of  successes 
that  prove  electricity  to  be  marvellous  as  a  curative 
agent  in  many  forms  of  disease.  The  doctor  can- 
not now  do  better  than  to  possess  himself  of  Dr. 
Bartholow's  treatise,  just  as  it  is. —  Virginia  Medi- 
cal Monthly,  June,  1887. 


YEO>  I.  BTJBNEY,  31.  IK,  F.  R.  C.  P., 

Professor  of  Clinical  Therapeutics  in  King's   College,  London,  and  Physician  to  King's   College 
Hospital. 

Food  in  Health  and  Disease.    In  one  12mo.  volume  of  590  pages.   Cloth,  $2. 
Just  ready.    See  Series  of  Clinical  3fanuals,  page  31. 
Dr.  Yeo  is  fully  master  of  his  subject  and  he  j  compass,  and  he  has  arranged  arid  digested  his 


supplies  in  a  compact  form  nearly  all  that  the 
practitioner  requires  to  know  on  the  subject  of 
diet.  The  work  is  divided  into  two  parts— food  in 
health  and  food  in  disease.  Dr.  Yeo  has  gathered 
together  from  all  quarters  an  immense  amount  of 
useful  information  within  a  comparatively  small 


materials  with  skill  for  the  use  of  the  practitioner. 
We  have  seldom  seen  a  book  which  more  thor- 
oughly realizes  the  object  for  which  it  was  written 
than  this  little  work  of  Dr.  Yeo. — British  Medical 
Journal,  Feb.  8, 1890. 


mcsABjysojs^,  b.  w.,  m.d.,  LL.n.,  mb.s., 

Fellow  of  the  Royal  College  of  Physicians,  London. 
Preventive  Medicine.    In  one  octavo  volume  of  729  pages.   Cloth,  $4;  leather,  $5, 


Dr.  Richardson  has  succeeded  in  producing  a 
work  which  is  elevated  in  conception,  comprehen- 
sive in  scope,  scientific  in  character,  systematic  in 
arrangement,  and  which  is  written  in  a  clear,  con- 
cise and  pleasant  manner.  He  evinces  the  happy 
faculty  of  extracting  the  pith  of  what  is  known  on 
the  subject,  and  of  presenting  it  in  a  most  simple, 
Intelligent  and  practical  form.  There  is  perhaps 
no  similar  work  written  for  the  general  public 
that  contains  such  acomplete,  reliable  and  instruc- 
tive collection  of  data  upon  the  diseases  common 
to  the  race,  their  origins,  causes,  and  the  measures 
for  their  prevention.  The  descriptions  of  diseases 
are  clear,  chaste  and  scholarly ;  the  discussion  of 


the  question  of  disease  is  comprehensive,  masterlv 
and  fully  abreast  with  the  latest  and  best  knowl- 
edge on  the  subject,  and  the  preventive  measures 
advised  are  accurate,  explicit  and  reliable.— TAe 
American  Journal  of  the  Medical  Sciences,  April,  1884. 

This  is  a  book  that  will  surely  find  a  place  on  the 
table  of  every  progressive  physician.  To  the  medi- 
cal profession,  whose  duty  is  quite  as  much  to 
prevent  as  to  cure  disease,  the  book  will  be  a  boon. 
— Boston  Medical  and  Surgical  Journal,  March  6,  '84. 

The  treatise  contains  a  vast  amount  of  solid,  val- 
uable hygienic  information. — Medical  and  Surgical 
Reporter,  Feb.  23,  1884. 


TSE  TEAB-BOOK  OF  TREATMENT  FOR  1890. 

A  Comprehensive  and  Critical  Review  for  Practitioners  of  Medi- 

3.     In  one  12mo.  volume  of  329  pages.    Cloth,  |1.25.     Just  ready. 
^(.\  For  special  commutations  with  periodicals  see  page  2. 


Cine 


In  the  present  issue  of  the  Year-Book  of  Treat- 
ment we  find  the  usual  clear,  concise,  complete 
and  accurate  epitome  of  the  chief  advances  made 
in  the  treatment  of  disease  during  the  year  end 
ing  Sept.  1st.  The  different  subjects  are  arranged 
in  sections  under  the  heads  of  the  principal  sys 


a  large  mass  of  information,  valuable  to  the  prac- 
titioner, is  presented  for  his  immediate  reference. 
Brief  notices  of  the  most  important  new  books  on 
each  subject  add  greatly  to  the  value  of  the  annual 
retrospect.  Such  a  book,  produced  as  it  is  in  an 
elegant  and  convenient  form  and  at  a  very  low 


terns  of  the  body.      The  serial  medical  literature    price,  ought  to  be  in  the  hands  of  every  member 
of  England,  America  and  of  the  Continent  has    of  the  prolession.— The  Practitioner,  Feb.  1890. 
been  laid  under  contribution,  with  the  result  that 

THE  TEAR- BOOKS  of  TREAT3IENT  for  1886-87-89. 

Similar  to  above.     12mo.,  320-341  pages.     Limp  cloth,  $1.25  each. 

8CHREIBER,  JOSEBEL,  M.  D. 

A  Manual  of  Treatment  by  Massage  and  Methodical  Muscle  Ex- 
ercise. Translated  by  Walter  Mendelson,  M.  D.,  of  New  York.  ^"  —  i.o.^c.^0 
octavo  volume  of  274  pages,  with  117  fine  engravings.     Cloth,  |2.7o. 

STURGES'    INTRODUCTION  TO  THE  STUDY 

OF  CLINICAL  MEDICINE.    Being  a  Guide  to 

the  Investigation  of  Disease.    In  one  handsome 

12mo.  volume  of  127  pages.    Cloth,  $1.25. 
DAVIS'   CLINICAL    LECTURES    ON  VARIOUS 

IMPORTANT    DISEASES.      By   N.   S.    Davis 

M.  D.  Edited  by  Frank  H.  Davis,  M.  D.  Second 

edition.    12mo.  287  pages.    Cloth,  81.75. 


In  one  handsome 


TODD'S  CLINICAL  LECTURES  ON  CERTAIN 
ACUTE  DISEASES.  In  one  octavo  volume  of 
320  pages.    Cloth,  82.50. 


PAVY'S  TREATISE  ON  THE  FUNCTION  OF  DI- 
GESTION; its  Disorders  and  their  Treatment. 
From  the  second  London  edition.  In  one  octavo 
volume  of  238  pages.    Cloth,  32.00.  „,„„„„ 

BARLOW'S  MANUAL  OF  THE  PR.A.CTICE  OF 
MEDICINE.  With  additions  by  D.  F.  Conkib, 
M.D.     1  vol.  8vo.,  pp.  603.     Cloth,  82.50. 

CHAMBERS'  MANUAL  OF  DIET  AND  REGIMEN 
IN  HEALTH  AND  SICKNESS.  In  one  hand- 
some octavo  volume  of  302  pp.    Cloth,  82.75^ 

HOLLAND'S  MEDICAL  NOTES  AND  REFLEC- 
TIONS. 1  vol.  Svc,  pp.  493.     Cloth,  83.50. 


18         Lea  Brothers  &  Co.'s  Publications — Throat,  Lunges,  Heart. 
FLINT,  AUSTIN,  M,  !>.,  LL.  2)., 

Profeisor  of  the  Principles  aiui  Practice  of  Medicine  in  Bellevue  Hospital  Medical  College,  N.  7. 

A.  Manual  of  Auscultation  and  Percussion ;    Of  the  Physical  Diagnosis  oi 

Diseases   of  llie    Lungs   iind    Heart,  and    of  Thoracic    Aneurism.      New  (fifth)  edition. 
Edited  by  James  C.  Wilson,  M.  D.,  Jetrerson  Medical  College,  Philadelphia.      In  one 
handsome  royal  12mo.  volume  of  about  300  pages,  with  14  illustrations.     Preparing. 
A  notice  of  the  previous  edition  is  appended. 
The  oriKinal  work  done  by  Dr.  Flint  in  the  devel-    passed  through  four  editions  attests  its  popularity, 

^     -X.L  -     __*     -r    _1 :«-!      -i: :^  .win     »1...«%Tn  rpL  ^..,.        ;,,      _       t^^A^^^^t       Arv^.-.n»       r.K.r.^;^«l        Ai^^^^t,** 


opmentofthe  art  of  physical  diagnosis  will  always 
make  this  manual  an  authority  on  this  subject. 
Among  all  the  works  issued  on  this  topic  during 
the  last  few  years,  none  exceeds  this  one  in  sim- 
plicity and  completeness.    The  fact  that  it  has 


There  is  a  tendency  among  physical  diagnosti- 
cians to  make  a  together  too  many  varieties  of 
morbid  chest  sounds,  and  especially  of  rales.  The 
conciseness  of  Dr.  Flint's  Manual  is  one  of  its  chief 
advantages  — Medical  Record,  June  IG,  1888. 


BY  THE  SAME  AUTHOR. 

A  Practical  Treatise  on  the  Physical  Exploration  of  the  Chest  and 
the  Diagnosis  of  Diseases  Affecting  the  Respiratory  Organs.  Second  and 
revised  edition.     In  one  handsome  octavo  volume  of  591  pages.     Cloth,  $4.50. 

Phthisis:  Its  Morbid  Anatomy,  Etiology,  Symptomatic  Events  and 
Complications,  Fatality  and  Prognosis,  Treatment  and  Physical  Diag- 
nosis ;  In  a  series  of  Clinical  Studies.     In  one  octavo  volume  of  442  pages.    Cloth,  $3.50. 

A  Practical  Treatise  on  the  Diagnosis,  Pathology  and  Treatment  of 

Diseases  of  the  Heart.     Second  revised  and  enlarged  edition.     In  one  octavo  volume 
of  550  pages,  with  a  plate.     Cloth,  $4. 

Essays  on  Conservative  Medicine  and  Kindred  Topics.  In  one  very  hand- 
some royal  12mo.  volume  of  210  pages.     Cloth,  $1.38. 


BROWNE,  LENNOX,  E,  R.  C.  S.,  E., 

Senior  Physician  to  the  Central  London  Throat  and  Ear  Hospital. 

A  Practical  Guide  to  Diseases  of  the  Throat  and  Nose,  including 
Associated  Afiections  of  the  Ear.  With  120  illustrations  in  color,  and  235  en- 
gravings on  wood.  New  (third)  and  enlarged  edition.  In  one  imperial  octavo  volume 
of  714  pages.     Cloth,  $6.50.     Just  ready. 


SELLER,  CARL,  M.  D., 

Lecturer  on  Laryngoscopy  in  tfie  University  of  Pennsylvania. 

A  Handbook  of  Diagnosis  and  Treatment  of  Diseases  of  the  Throat, 
Nose  and  Naso-Pharynx.  New  (third)  edition.  In  one  handsome  royal  12mo. 
volume  of  373  pages,  with  101  illustrations  and  2  colored  plates.     Cloth,  $2.25. 

Few  medical  writers  surpass  this  author  in  [  of  topics  and  methods.  The  book  deserves  a  large 
ability  to  make  his  meaning  perfectly  clear  In  a  sale,  especially  among  general  practitioners — Chi- 
few  words,  and  in  discrimination  in  selection,  both  1  cago  Medical  Journal  and  Examiner,  April,  1889. 


COHEN,  J.  SOLLS,  M.  D., 

Lecturer  on  Laryngoscopy  and  Diseases  of  the  Throat  and  Chest  in  the  Jefferson  Medical  College. 

Diseases  of  the  Throat  and  Nasal  Passages.  A  Guide  to  the  Diagnosis  and 
Treatment  of  Aflections  of  the  Pharynx,  Oesophagus,  Trachea,  Larynx  and  Nares.  Third 
edition,  thoroughly  revised  and  rewritten,  with  a  large  number  of  new  illustrations.  In 
one  very  handsome  octavo  volume.     Preparing. 

GROSS,  S.  n.,  M.D.,  LL.D,,  D.C.L.  Oxon,,  LL.D.  Cantab, 

A  Practical  Treatise  on  Foreign  Bodies  in  the  Air-passages.    In  one 

octavo  volume  of  452  pages,  with  59  illustrations.     Cloth,  $2.75. 

BROADBENT,  W.  H.,  M.  D,,  F.  R,  C.  F,, 

Physician  to  and  Lecturer  on  Medicine  at  St.  Mary's  Hospital,  London. 
The  Pulse.     In  one  12mo.  volume  of  312  pages.    Cloth,  $1.75.    Jiist  ready.    See 
/Series  of  Clinical  Manuals,  page  31. 

FULLER  ON  DISEASES  OF  THE  LUNGS  AND        valence  in  various  Countries.  Second  and  revised 

AIR-PASSAGES.  Their  Pathology,  Physical  Di-        edition.    In  one  12mo.  vol.,  pp.  158.    Cloth,  J1.25. 

agnosis,  Symptoms  and  Treatment.    From  the    SMITH  ON  CONSUMPTION  ;  its  Early  and  Reme- 

second   and    revised  English  edition.     In  one       diable  Stages.    1  vol.  8vo.,  pp.  253.    Cloth,  82.25. 

octavo  volume  of  475  pages.    Cloth,  83.50.  LA  ROCHE  ON  PNEUMONIA.    1  vol.  8vo.  of  490 

WALSHE  ON  THE  DISEASES  OF  THE  HEART        pages.    Cloth,83.00. 

AND  GREAT  VESSELS.    Third  American  edi-  ,  WILLIAMS  ON  PULMONARY  CONSUMPTION; 

tion.    In  1  vol.  8vo.,  416  pp.    Cloth,  83.00.  its  Nature,  Varieties  and  Treatment.    With  an 

8LADE  ON  DIPHTHERIA;  its  Nature  and  Treats       analysis  of  one  thousand  cases  to  exemplify  it8 

ment,  wiUi  an  account  of  the  History  of  its  Pre-  |      duration.  In  one  8vo.  vol.  of  303  pp.  Cloth,  $2.50 


Lea  Brothers  &  Co.'s  Publications — Nerv.  and.  Ment.  Dis.,  etc.     19 


MOSS,  JAMES,  II.  n.,  F,M.  C.P.,  LL.JD., 

Senior  Assistant  Physician  to  the  Manchester  Royal  Infirmary. 

A  Handbook  on  Diseases  of  the  Nervous   System.     In  one  octavo 
volume  of  725  pages,  with  184  illustrations.     Cloth,  $4.50 ;  leather,  $5.50. 

This  admirable  worli  is  intended  for  students  of  the  department  of  medicine  of  which  it  treats. 
laedicine  and  for  suchmedical  menas have  notime  Dr.  Ross  holds  such  a  high  scientific  nosition  that 
for  lengthy  treatises.  In  the  present  instance  the  any  writings  which  bear  his  name  are  naturally 
duty  of  arranging  the  vast  store  of  material  at  the  expected  to  have  the  impress  of  a  powertui  intei- 
disposal  of  the  author,  and  of  abridging  the  de-  leet.  In  every  part  this  handbook  merits  tne 
scription  of  the  different  aspects  of  nervous  dis-  highest  praise,  and  will  no  doubt  be  found  of  the 
eases,  has  been  performed  with  singular  skill,  and  greatest  value  to  the  student  as  well  as  to  the  prac- 
the  result  is  a  concise  and  philosophical  guide  to  \  titioner.^ EiUnburgh  MedicalJournal,  Jan.  1887. 

MITCHELL,  S.  WEIM,  M.  D., 

Physician  to  Orthopcedic  Hospital  and  the  Infirmary  for  Diseases  of  the  Nervous  System  Phila.  etc. 

Lectures  on  Diseases  of  the  Nervous  System;  Especially  in  Women. 
Second  edition.     In  one  12mo.  volume  of  288  pages.     Cloth,  $1.75. 

No  work  in  our  language  develops  or  displays  i  teachings  the  stamp  of  authority  all  over  the 
more  features  of  that  many-sided  affection,  hys-  J  realm  of  medicine.  The  work,  although  written 
teria,  or  gives  clearer  directions  for  its  differen-  by  a  specialist,  has  no  exclusive  character,  and 
tiation,  or  sounder  suggestions  relative  to  its  |  the  general  practitioner  above  all  others  will'  find 
general  management  and  treatment.  The  book  j  its  perusal  profitable,  since  it  deals  with  diseases 
IS  pai-ticularly  valuable  in  that  it  represents  in  \  which  he  frequently  encounters  and  must  essay 
the  main  the  author's  own  clinical  studies,  which  i  to  treat. — American  Practitioner,  August,  1885. 
have  been  so  extensive  and  fruitful  as  to  give  his  j 


SAMILTOJS^,  ALLAJS^  McLAJS^E,  M.  !>., 

Attending  Physician  at  the  Hospital  for  Epileptics  and  Paralytics,  BlackwelVs  Island,  N.  T. 

Nervous  Diseases ;  Their  Description  and  Treatment.     Second  edition,  thoroughly 

revised  and  re-\vritten.    In  one  octavo  volume  of  598  pages,  with  72  illustrations.    Cloth,  $4. 

When  the  first  edition  of  this  good  book  appeared  :  characterized  this  book  as  the  best  of  its  kind  in 

we  gave  it  our  emphatic   endorsement,  and  the  \  any  language,  which  is  a  handsome  endorsement 

E resent  edition  enhances  our  appreciation  of  the     from  an  exalted  source.  The  improvements  in  the 
ook  and  its  author  as  a  safe  guide  to  students  of    new  edition,  and  the  additions  to  it,  will  justify  its 

clinical  neurology.      One  of  the  best  and  most    purchase  even  by  those  who  possess  the  old. 

critical  of  English  neurological  journals,  Brain,  has    Alienist  and  Neurologist,  April,  1882. 

TUKE,  DAJVIEL  HACK,  M.  2>., 

Joint  Author  of  The  Manual  of  Psychological  Medicine,  etc. 

Illustrations  of  the  Influence  of  the  Mind  upon  the  Body  in  Health 
and  Disease.  Designed  to  elucidate  the  Action  of  the  Imagination.  New  edition. 
Thoroughly  revised  and  rewritten.  In  one  Svo.  vol.  of  467  pp.,  with  2  col.  plates.   Cloth,  $3. 

It  is  impossible  to  peruse  these  interesting  chap-  i  method  of  interpretation.  Guided  by  an  enlight- 
ters  without  being  convinced  of  the  author's  per-  i  ened  deduction,  the  author  has  reclaimed  for 
feet  sincerity,  impartiality,  and  thorough  mental  j  science  a  most  interesting  domain  in  psychology, 
grasp.  Dr.  Take  has  exhibited  the  requisite  i  previously  abandoned  to  charlatans  and  empirics, 
amount  of  scientific  address  on  all  occasions,  and  This  book,  well  conceived  and  well  written,  must 
the  more  intricate  the  phenomena  the  more  firmly  commend  itself  to  every  thoughtful  understand- 
has   he  adhered  to  a  physiological  and  rational  |  ing. — New  Fori;  ilffdica/ JoMrnai,  September  6, 1884. 

CLOUSTO]^,  THOMAS  S.,  M,  !>,,  F.  B.  C.  JP.,  L,  B,  C,  S., 

Lecturer  on  Mental  Diseases  in  the  University  of  Edinburgh. 

Clinical  Lectures  on  Mental  Diseases.  With  an  Appendix,  containing  an 
Abstract  of  the  Statutes  of  the  United  States  and  of  the  Several  States  and  Territories  re- 
lating to  the  Custody  of  the  Insane.  By  Charles  F.  Folsom,  M.  D.,  Assistant  Professor 
of  Mental  Diseases,  Med.  Dep.  of  Harvard  Univ.  In  one  handsome  octavo  volume  of  541 
pages,  with  eight  lithographic  plates,  four  of  which  are  beautifully  colored.  Cloth,  $4. 
The  practitioner  as  well  as  the  student  will  ac-  [  the  general  practitioner  in  guiding  him  to  a  diag- 
■     '  '       '  ■         "'"  .1         _  _  ,        ._  -_j  ;_  i;-_i!.-_  ^jjg  treatment,  especially  in 

cases  of  mental  dis- 


cept  the  plain,  practical  teaching  of  the  author  as  a  |  nosis  and  indicating  the  tr 
forward  step  in  the  literature  of  insanity.    It  is  j  many  obscure  and  doubtful 


To  the  American  reader  Dr.  Folsom's  Ap- 
pendix adds  greatly  to  the  value  of  the  work,  and 
will  m  iiie  it  a  desirabie  addition  to  every  library. 
— American  Psychological  Jow^nal,  July,  1884. 


refreshing  to  find  a  physician  of  Dr.  Clouston's 
experience  and  high  reputation  giving  the  bed- 
side notes  upon  which  his  experienct  has  been 
founded  and  his  mature  judgment  established. 
Such  clinical  observations  cannot  but  be  useful  to 

g®"Dr.  Folsom's  Abstract  may  also  be  obtained  separately  in  one  octavo  volume  of 
108  pages.     Cloth,  $1.50. 

SAVAGE,  GEORGE  H.,  M.  I),, 

Lecturer  on  Mental  Diseases  at  Gfuy's  Hospital,  London. 
Insanity  and   Allied  Neuroses,  Practical  and  Clinical.     In  one  12mo.  vol. 
of  551  pages,  with  18  illus.     Cloth,  $2.00.     See  Series  of  Clinical  Manuals,  page  31. 

rLAYFAIB,  W.  S.,  M,  I).,  F,  B.  C,  JP. 

The  Systematic  Treatment  of  Nerve  Prostration  and  Hysteria.    In 

one  handsome  small  12mo.  volume  of  97  pages.     Cloth,  $1.00. 

Blandford  on  Insanity  and  its  Treatment:   Lectures  on  the  Treatment, 

Medical  and  Legal,  of  Insane  Patients.    In  one  very  nandsome  octavo  volume. 

Jones'   Clinical  Observations   on  Functional   Nervous   Disorders. 
Second  American  Edition.     In  one  handsome  octavo  volume  of  340  pages.     Cloth,  $3.25. 


20  Lea  Brothers  &  Co.'s  Publications — Surgery. 

ASHHUBST,  JOHN,  Jr.,  M.  !>., 

Barton  Prof,  of  Surgery  and  Clin.  Surgery  in  Unit',  of  Penna.,  Surgeon  to  the  Penna.  Hosp.,  etc. 

The  Principles  and  Practice  of  Surgery.  New  (fifth)  edition,  enlarged 
and  thorouglily  revised.  In  one  large  and  handsome  octavo  volume  of  1144  pages,  with 
642  illustrations.     Cloth,  $6  ;  leather,  $7.     Just  ready. 


A  complete  and  most  excellent  work  on  surgery. 
It  is  only  necessary  to  examine  it  to  see  at  once 
its  excellence  and  real  merit  either  as  te.\t-book 
for  the  student  or  a  guide  for  the  general  practi- 
tioner. It  fully  considers  in  detail  every  surgical 
injury  and  disease  to  which  the  body  is  liable,  and 


best  and  most  complete  single  volume  on  surgery, 
in  the  English  language,  and  cannot  but  receive 
that  continued  appreciation  which  its  merit.«  justly 
demand.— 6'ciu/iern  Practiliooer,  Feb.  1890. 


This  is  one  of  the  most  popular  and  useful  ot 
the  many  well-known  treatises  on  general  surgery. 
It  furnishes  in  a  concise  manner  a  clear  and 
comprehensive  description  of  the  modes  of  prac- 
tice now  generally  employed  in  the  treatment  of 
surgical  atTections,  with  a  plain  exposition  of  the 


every  advance  in  surgery  worth  noting  is  to  be    principles  on  which  those  modes  of  practice  are 
found  in  its  proper  place.    It  is  unquestionably  the    based.  The  entire  j,vork  hasbeen  carefully  revised. 


and  a  number  of  new  illustrations  introduced 
that  greatly  enhance  the  value  of  the  book. — 
Ciucianati  Lancet -Clinic,  Dec.  14, 1889. 


DBUITT,  ROBERT,  M,  B,  C.  S,,  etc. 

Manual  of  Modern  Surgery.  Twelfth  edition,  thoroughly  revised  by  Stan- 
ley Boyd,  M.B.,  B.  S.,  F.  R.  C.  S.  In  one  8vo.  volume  of  965  pages,  with  373  illustra- 
tions.    Cloth,  $4 ;  leather,  $5. 

It  is  essentially  a  new  book,  rewritten  from  be-  ■  Druitt's  Surgery  has  been  an  exceedingly  popu- 
ginning  to  end.  The  editor  has  brought  his  work  lar  work  in  the  profession.  It  is  stated  that  50,000 
up  to  the  latest  date,  and  nearly  every  subject  on  copies  have  been  sold  in  England,  while  in  the 
wnich  the  student  and  practitioner  would  desire  '  United  Stales,  ever  since  its  first  issue,  it  has  been 
to  consult  a  surgical  volume,  has  found  its  place  used  as  a  text-book  to  a  very  large  extent.  Dur- 
here.  The  volume  closes  with  about  twenty  pages  ing  the  late  war  in  this  country  it  was  so  highly 
of  formulw  covering  a  broad  range  of  practical  appreciated  that  a  copy  was  issued  by  the  Govern- 
therapeutics.  The  student  will  find  that  the  new  ment  to  each  surgeon.  The  present  edition,  while 
Druitt  is  to  this  generation  what  the  old  one  was  it  has  the  same  features  peculiar  to  the  work  at 
to  the  former,  and  no  higher  praise  need  be  first,  embodies  all  recent  discoveries  in  surgery, 
accorded  to  any  volume. — Xoi'th  Carolina  Medical  ,  and  is  fully  up  to  the  times.  Cincinnati  Medical 
Journal,  October,  1887.  I  Keics,  September,  1887. 

GANT,  FBBDEBICK  JAMES,  F.  B.  C.  S., 

Senior  Surgeon  to  the  Royal  Free  Hospital. 

The  Student's  Surgery.  A  Jlultmn  in  Pano.  In  one  square  octavo  volume 
of  848  pages,  with  159  engravings.     Cloth,  $3.75. 

The  claims  of  this  volume  to  be  a  multum  in  subjects.  The  volume  is  a  condensation  of  the 
parvo  are  certainly  substantiated.  The  author  '  author's  well-known  larger  works  on  surgery, 
covers  the  whole  field  of  clinical  and  operative  notably  his  "  Science  and  Practice  of  Surgery  ". 
surgerv  in  about  eight  hundred  pages  of  very  com- j  Students  requiring  the  essentials  of  surgery 
pacily  printed  matter.    For  a  student's  manual  it  ,  in  a  handy  and  condensed  form,  and  those  who 


appears  to  us  in  every  wav  excellent,  containing  j  cannot  devote  time  to  theoretical  or  speculative 
almost  everything  necessary  to  equip  tlie  student  I  pathology  will  find  this  volume  exceedingly  ser- 
with  sound,  matter-of-fact  knowledge  on  surgical  |  vlceable.— 7Vie  Physician  and  Surgeon,  April,  1890 


BOBEBTS,  J.  B.,  M.  D., 

Professor  of  Anatomy  and  Surgery  in  the  Philadelphia  Polyclinic.    Professor  of  the  Principles  and 
practice  of  Surgery  in  the  Roman's  Medical  College  of  Pennsylvania. 

The  Principles  and  Practice  of  Modern  Surgery.  For  the  use  of  Students 
and  Practitioners  of  Medicine  and  Surgery.  In  one  very  handsome  octavo  volume  of  about 
830  pages,  with  about  425  illustrations.     In  press. 

In  this  volume,  as  its  title  indicates,  the  author  has  endeavored  to  give  a  thorough 
exposition  of  the  best  surgical  practice  of  the  present  time.  Not  relying  on  his  own 
larf'e  experience,  he  has  consulted  the  latest  literature  of  all  kinds  bearing  on  his  spec- 
ialty, and  has  gleaned  therefrom  the  opinions  of  the  best  authorities,  and  the  methods  of 
the  most  practical  surgeons.  The  well-established  facts  of  the  scien'^e  are  clearly  stated, 
but  history,  theories  and  untried  innovations  are  rigidly  excluded.  The  work  is  richly 
illustrated.  In  the  selection  of  matter  and  in  the  consideration  of  the  vast  number  of 
questions  involved,  the  author  has  used  his  most  critical  judgment  in  the  endeavor  to 
render  the  work  of  the  greatest  practical  advantage  to  both  practitioners  and  students. 

GBOSS,  S.  D.,  M.  JD.,  LL.  D.,  JD.  C.  L.  Oxon.,  LL.  D, 
Cantab., 

Emeritus  Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 

A  System  of  Surgery:  Pathological,  Diagnostic,  Therapeutic  and  Operative. 
Sixth  edition,  thoroughly  revised  and  greatly  improved.  In  two  large  and  beautifully- 
printed  imperial  octavo  volumes  containing  2382  pages,  illustrated  by  1623  engravings. 
Strongly  bound  in  leather,  raised  bands,  $15. 

BALL,  CBLABLESli.,  M.  Ch.,  I>iib.,  E.  B.  C.  S.,  E., 

Surgeon  and  Teacher  at  Sir  P.  Dun's  Hospital,  Dublin. 

Diseases  of  the  Rectum  and  Anus.  In  one  12mo.  volume  of  417  pages, 
with  54  engravings  and  4  colored  plates  Cloth,  $2.25.  Just  ready.  See  Series  of  Clinical 
Manuals,  page  31. 

GIBJSTET,  F.  B.,  M.  !>., 

Surgeon  to  the  Orthopaedic  Hospital,  New  York,  etc. 
Orthopaedic  Surgery.    For  the  use  of  Practitioners  and  Students.    In  one  hand- 
some octavo  volume,  profusely  illustrated.     Preparing. 


Lea  Brothers  &  Co.'s  Publications — Surg-ery. 


21 


:ericss:ew,  jobj^  m,  ^.  b.  s.,  f.  m.  a  s,, 

Professor  of  Surgery  in  University  College,  London,  etc. 

The"  Science  and  Art  of  Surgery ;  Being  a  Treatise  on  Surgical  Injuries,  Dis- 
eases and  Operations.  From  the  eighth  and  enlarged  English  edition.  In  two  large  and 
beautiful  octavo  volumes  of  2316  pages,  illustrated  with  984  engravings  on  wood. 
Clotli,  $9;  leather,  raised  bands,  $11. 

We  have  always  regarded  "The  Science  and  [  marked  the  progress  of  surgery  during  the  last 
Art  of  Surgery"  as  one  of  the  best  surgical  text^  j  decade  has  been  omitted.  The  illustrations  are 
books  in    the    English  language,  and  this  eighth  j  many  and  executed  in  the  highest  style  of  art. 


edition  only  confirms  our  previous  opinion.  We 
take  great  pleasure  in  cordially  commending  it  to 
our  readers. —  The  Medical  News,  April  11,  1885. 

For  many  years  this  classic  work  has  been 
made  by  preference  of  teachers  the  principal 
text-book  on  surgery  for  medical  students,  while 
through  translations  into  the  leading  continental 
languages  it  may  be  said  to  guide  the  surgical 
teachings  of  the  civilized  world.  No  excellence 
of  the  former  edition  has  been  dropped  and  no 
discovery,    device    or    improvement    which    has 


Lriuisvitle  Medical  News,  Feb.  14,  1885. 

We  cannot  speak  too  highly  of  this  excellent 
work.  It  represents  the  most  advanced  and  settled 
views  in  regard  to  the  science  of  surgery,  and  will 
ever  be  found  a  faithful  guide  and  counsellor  in 
practice. — Canada  Lancet,  May,  1885. 

It  appears  simultaneously  in  England,  America, 
Spain  and  Italy,  and  is  too  well  known  as  a  safe 
guide  and  familiar  friend  to  need  further  com- 
ment.— New  York  Medical  Journal,  March  28, 1885. 


BBTAWT,  TJSOMAS,  F.  B.  C,  S,, 

Surgeon  and  Lecturer  on  Surgery  at  Chiy's  Hospital,  London. 
The  Practice  of  Surgery.     Fourth  American  from  the  fourth  and  revised  Eng- 
lish edition.     In  one  large  and  very  handsome  imperial  octavo  volume  of  1040  pages,  with 
727  illustrations.     Cloth,  $6.50 ;  leather,  $7.50. 

The  fourth  edition  of  this  work  is  fully  abreast  |  enable  the  busy  practitioner  to  review  any  subject 
of  the  times.  The  author  handles  his  subjects  j  in  every-day  practice  in  a  short  time.  No  time  is 
with  that  degree  of  judgment  and  skill  which  is  ,  lost  with  useless  theories  or  superfluous  verbiage, 
attained  by  years  of  patient  toil  and  varied  ex-  |  In  short,  the_work  is  eminently  clear,  logical  and 


perience.  The  present  edition  is  a  thorough  re- 
vision of  those  which  preceded  it,  with  much  new 
matter  added.  His  diction  is  so  graceful  and 
logical,  and  his  explanations  are  so  lucid,  as  to 
place  the  work  among  the  highest  order  of  text- 
books for  the  medical  student.  Almost  every 
topic  in  surgery  is  presented  in  such  a  form  as  to 


practical. — Chicago  Medical  Journal  and  Examiner, 
April,  1886. 

This  book  is  essentially  what  it  purports  to  be, 
viz.:  a  manual  for  the  practice  of  surgery.  It  is 
peculiarly  well  fi  tted  for  the  student  or  busy  general 
practitioner. —  The  Medical  Neios,  August  15,  1885. 


TBBVES,  FBEDBBICK,  F.  B.  C.  S., 

Hunterian  Professor  at  the  Royal  College  of  Surgeons  of  England. 
A  Manual    of   Surgery.     In  Treatises  by  Various  Authors.     In  three  12mo. 
volumes,  containing  1866  pages,  with  213  engravings.     Price  per  volume,  cloth,  $2.     See 
Students'  Series  of  Manuals,  page  31. 


We  have  here  the  opinions  of  thirty-three 
authors,  in  an  encyclopsedic  form  for  easy  and 
ready  reference.  The  three  volumes  embrace 
every  variety  of  surgical  affections  likely  to  be 
met  with,  the  paragraphs  are  short  and  pithy,  and 


the  salient  points  and  the  beginnings  of  new  sub- 
jects are  always  printed  in  extra-heavy  type,  so 
that  a  person  may  find  whatever  information  he 
may  be  in  need  of  at  a  moment's  glance. — Cin- 
cinnati Lancet-Clinic,  August  21, 1886. 


MABSS,  SOWABn,  F,  B.  C.  S., 

Senior  Assistant  Surgeon  to  and  Lecturer  on  Anatomy  at  St.  Bartholomew's  Hospital,  London. 
Diseases  of  the  Joints.     In  one  12mo.  volume  of  468  pages,  with  64  woodcuts 
and  a  colored  plate.     Cloth,  $2.00.     See  Series  of  Clinical  Manuals,  page  31. 

BTTTLIN,  SFJ^BT  T.,  F,  B.  C.  S., 

Assistant  Surgeon  to  St.  Bartholomew's  Hospital,  London. 
Diseases    of   the    Tongue.      In  one  12mo.  volume  of  456  pages,  with  8  colored 
plates  and  3  woodcuts.     Cloth,  $3.50.     See  Series  of  Clinical  Manuals,  page  31. 

The  language  of  the  text  is  clear  and  concise,    veniently  scattered  through  general  works  on  sur- 
The  author  has  aimed  to  state  facts  rather  than  to    gery  and  the  practice  of  medicine.    The  physician 
express  opinions  and  has  compressed  within  the    and  surgeon  will  appreciate  its  value  as  an  aid  and 
compass  of  this  small  volume  the  pathology,  etiol-    gnide.— Physician  and  Surgeon,  Sept.  1886. 
ogy,  etc.,  of  diseases  of  the  tongue  that  are  incon- 


TBEVBS,  FBEJyBBICK,  F.  B.  C,  S., 

Surgeon  to  and  Lecturer  on  Surgery  at  the  London  Hospital.  r  r^^  •  -i    en 

Intestinal  Obstruction.    In  one  pocket-size  12mo.  volume  of  522  pages,  with  60 


illustrations.  Limp  cloth,  blue  edges,  $2.00. 

A  standard  work  on  a  subject  that  has  not  been 
so  comprehensively  treated  by  any  contemporary 
English  writer.  Its  completeness  renders  a  full 
review  difficult,  since  every  chapter  deserves  mi- 
nute attention,  and  it  is  impossible  to  do  thorough 


See  Sej'ies  of  Clinical  Manuals,  page  31. 
justice  to  the  author  in  a  few  paragraphs.  Intes- 
tinal  Obstruction  is  a  work  that  will  prove  of 
equal  value  to  the  practitioner,  the  student,  the 
pathologist,  the  physician  and  the  operating  sur- 
geon.— British  Medical  Journal,  Jan.  31,  1885. 


GOULD,  A.  FEABCE,  M.  S.,  M.  B.,  F.  B.  C.  S„ 

Assistant  Surgeon  to  Middlesex  Hospital.  ■ 

Elements  of  Surgical  Diagnosis.    In  one  pocket-size  12mo.  volume  of  &89 
pages.     Cloth,  $2.00.     See  Students'  Series  of  Manuals,  page  31. 


PIRRIE'S  PRINCIPLES  AND  PRACTICE  OF 
SURGERY.  Edited  by  John  Neeli.,  M.  D.  In 
one  8vo.  vol.  of  784  pp.  with  316  illus.    Cloth,  ?3.7o. 

MILLER'S  PRINCIPLES  OF  SUR&ERY.  Fourth 
American  from  the  third  Edinburgh  edition.  In 


one  8vo.  vol.  of  638  pages,  with  340  illustrations. 
Cloth,  S3.75. 
MILLER'S  PRACTICE  OF  SURGERY.     Fourth 
and  revised  American  edition.    In  one  large  Svo. 
vol.  of  682  pp.,  with  364  illustrations.    Cloth,  $3.76. 


22      Lea  Brothers  &  Co.'s  Publications — Surgery,  Frac.,  Disloc. 


SMITH,  STEPHEN,  M.  !>., 

Professni  <i(  Cli'iicni  Siirf/iri/  in  the  (hiiver.iih/  of  the  City  of  New  York. 

The  Principles  and  Practice  of  Operative  Surgery.  New  (second)  and 
thoroughlv  revise<l  edition.  In  one  very  handsome  octavo  volume  of  892  pages,  with 
lOOo  iUnstrations.     Cloth,  ?  100;  lcather,'ji5.00. 

This  excellent  and  very  valuable  hook  is  one  of  '  tie  surgery,  and  the  latest  instruments  known  for 
the  most  satisfactory  works  on  modern  operative  operative  work.  It  can  be  truly  said  that  as  a  hand- 
surgery  ytt  published.  Its  author  and  publisher  book  for  the  student,  acompanion  forthe  surj^eon, 
have  spareii  no  pains  to  make  it  as  far  as  iiossible  and  even  as  a  book  of  r^ft-rence  for  the  physician 
an  ideal,  and  their  efforts  have  given  it  a  position  not  especially  engaged  in  the  practice  or  .-urgery, 
prominent  among  the  recent  works  in  this  depart-  this  volume  will  long  hold  a  most  conspicuous 
ment  of  surgery.  The  book  is  a  compendium  for  place,  and  seldom  willits  readers,  no  matter  how 
the  modern  surgeon.  The  present,  the  only  rfrwe</  unusual  the  subject, consult  its  pages  in  vain.  Its 
edition  since  isV'.t,  presents  many  changes  from  compact  form,  excellent  print,  numerous  illustra- 
the  original  manual.  The  volume  is  much  eh  '  tions,  and  especially  its  itecidedly  practical  char- 
larged,  and  the  text  has  been  thoroughly  revised,  |  acter,  all  combine  to  commend  \i.— Boston  Medical 
80  as  to  give  the  most  improved  methods  in  asep-  i  and  Surgical  Journal,  May  10,  1888. 

HOL3IES,  TIMOTHY,  M,  JL., 

Surgeon  and  Ltcfurer  on  Surgc.ri/  at  St.  George's  Iloapitnl,  London. 

A  Treatise  on  Surgery ;  Its  Principles  and  Practice.  New  American 
from  the  lifth  Englisii  edition,  edited  hy  T.  Pickering  Pick,  F.  R.  C.  S.,  Surgeon  and 
Lecturer  on  Surgery  at  St.  George's  Hospital,  London.  In  one  octavo  volume  of  997 
pages,  with  428  illustrations.     Cloth,  $6;  leather,  $7.     Jiist  ready. 

To  the  younger  members  of  the  profession  and  for  the  general  practitioner,  teaching  those  thines 
to  others  not  acquainted  with  the  book  and  its  that  are  necessary  to  be  known  for  ine  successful 
merits,  we  take  pleasure  in  recommending  it  as  a  pro  ecution  of  the  physician's  career,  imparting 
surgery  complete,  thorough,  well- written,  fully  nothing  that  in  our  present  knowledge  is  consid- 
illustrated,  modern,  a  work  sufficiently  \olunii-  ered  unsafe,  unscientific  or  inexpedient.— Paci/lc 
nous  for  the  surgeon  specialist,  adequately  concise  ,  Medical  Journal,  July,  1889. 

HOLMES,  TIMOTHY,  MA^, 

Surqeon  and  Lecturer  on  Surgery  at  St.  George's  Hospital,  London. 

A  System  of  Surgery ;  Theoretical  and  Practical.  IN  TREATISES  BY 
VARIOUS  AUTHORS,  .\merican  edition,  thoroughly  revised  and  re-editeo) 
by  John  H.  Packard,  M.  D.,  Surgeon  to  the  Episcopal  and  St.  Joseph's  Hospitals, 
Philadelphia,  assisted  hy  a  corps  of  thirty-three  of  the  most  eminent  American  surgeons. 
In  three  large  imperial  octavo  volumes  containing  3137  double- coiumned  pages,  with 
979  illustrations  on  wood  and  13  lithographic  plates,  beautifully  colored.  Price  per 
set,  cloth,  $18.00;  leather,  $21.00.     Sold  only  by  subscription. 

STIMSON,  LEWIS  A.,  B,  A,,  M,  H,, 

Surgeon  to  the  Presbyterian  and  BelUvue  Hospitals,  Professor  of  Clinical  Suraery  in  the  Medical 
Faculty  of  Univ.  of  City  of  N.    V.,  Corresponding  Member  of  the  Societe  de  Chirurgie  of  Paris. 
A  Manual  of  Operative  Surgery.     New  (second)  edition.     In  one  very  hand- 
some royal  12mo.  volume  of  503  pages,  with  342  illustrations.     Cloth,  $2.50. 

There  is  always  room  for  a  good  book,  so  that  '  effected  in  operative  methods  and  procedures  by 
while  many  works  on  operative  surgery  must  be  the  antiseptic  system,  and  has  added  an  account 
considered  superfluous,  that  of  Dr.  Stimson  has  !  of  many  new  operations  and  variations  in  the 
held  its  own.  The  author  knows  the  difficult  art  steps  of  older  operations.  We  do  not  desire  to 
of  condensation.  Thus  the  manual  serves  as  a  ]  extol  this  manual  above  many  excellent  st&ndard 
work  of  reference,  and  at  the  same  time  as  a  ;  British  publications  of  the  same  class,  still  we  1)6- 
handy  guide.  It  teaches  what  it  professes,  the  !  lieve  that  it  contains  much  that  is  worthy  of  iml- 
eteps  of  operations.  In  this  edition  Dr.  Stimson  |  tation. — British  Medical  Journal,  Jan.  22, 1887. 
has  sought  to  indicate  the  changes  that  have  been  | 

By  the  same  Author. 
A  Treatise  on  Fractures  and  Dislocations.    In  two  handsome  octavo  vol- 
umes.   Vol.  I.,  Fractures,  5?>2  pages,  360  beautiful  illustrations.    Vol.  II.,  Disloca- 
tions, 540  pages,  with  163  illustrations.     Complete  work,  cloth,  $5.50;   leather,  $7.50. 
Either  volume  separately,  cloth,  $3.00;  leather,  $4.00. 

The  appearance  of  the  second  volume  marks  the  of  Dislocations  as  it  is  taught  and  practised  by  the 
completion  of  the  author's  original  plan  of  prepar  most  eminent  surgeons  of  the  present  time.  Con- 
ing a  work  which  should  present  in  the  fullest  taining  the  results  of  such  extended  researches  it 
manner  all  that  is  known  on  the  cognate  subjects  must  for  a  long  time  be  regarded  as  an  authority 
of  Fractures  and  Dislocations.  The  volume  on  on  all  subjects  pertaining  to  dislocations.  Every 
Fractures  assumed  at  once  the  position  of  authority  practitioner  of  surgery  will  feel  it  incumbent  on 
on  the  subject,  and  its  companiOQ  on  Dislocations  him  to  have  it  for  constant  reference. — Cincinnati 
will  no  doubt  be  similarly  received.  The  closing  Medical  News,  May,  1888. 
volume  of  Dr.  Stimson's  work  exhibits  the  surgery 

HAMILTON,  FRAJNK  H.,  M,  D.,  LL,  D., 

Surgeon  to  Bellevue  Hospital,  New  York. 

A  Practical  Treatise  on  Fractures  and  Dislocations.  Seventh  edition 
thoroughly  revised  and  much  improved.  In  one  very  handsome  octavo  volume  of  998 
pages,  with  379  illustrations.     Cloth,  $5.50 :  leather,  $6.50. 

This  book  is  without  a  rival  in  any  language.    It    fully  given.   The  book  is  so  well  known  that  it  does 
is  essentially  a  practical  treatise,  and  it  gathers    not  require  any  lengthened  review.    We  can  only 
within  its  covers  almost  everything  valuable  that    say   that  it  is  still  unapproached  as  a  treatise.— 
has  been  written  about  fractures  and  dislocations.     The  Dublin  Journal  of  Medical  Science,  Feb.  1886. 
The  principles  and  methods  of  treatment  are  very 

PICK,  T.  PICKERING,  F,  B.  C,  S., 

Surgeon  to  and  Lecturer  on  Surgery  at  St.  George's  Hospital,  London. 

Fractures  and  Dislocations.  In  one  12mo.  volume  of  530  pages,  with  93 
illustrations.     Limp  cloth,  $2.00.     See  Series  of  Clinical  Manuals,  page  31. 


Lea  Brothers  &  Co.'s  Publications — Otol.,  Ophtlial.  23 


BVBJSTETT,  CMAMLBS  JEL,,  A.  M,,  W.  D., 

Professor  of  Otology  in  the  Philadelphia  Polyclinic ;  President  of  the  American  Otological  Society. 

The  Ear,  Its  Anatomy..  Physiology  and  Diseases.  A  Practical  Treatise 
for  the  use  of  Medical  Students  and  Practitioners.  Second  edition.  In  one  handsome 
octavo  volume  of  580  pages,  with  107  ilhistrations.   Cloth,  §4.00 ;  leather,  $5.00. 

We  note  with  pleasure  the  appearance  of  a  second  carried  out,  and  much  new  matter  added.  Dr 
edition  of  this  valuable  work.  When  it  first  came  Burnett's  work  must  be  regarded  as  a  very  valua- 
out  it  was  accepted  by  the  profession  as  one  of  ble  contribution  to  aural  surgery,  not  only  on 
the  standard  works  on  modern  aural  surgery  in  account  of  its  comprehensiveness,  but  because  it 
the  English  language;  and  in  his  second  edition  contains  the  results  of  the  careful  personal  observa- 
Dr.  Burnett  has  fully  maintained  his  reputation,  ,  tion  and  experience  of  this  eminent  aural  surgeon, 
for  the  book  is  replete  with  valuable  information  —London  Lancet,  Feb.  21,  1885. 
and  suggestions.    The  revision  has  been  carefully  ! 


POLITZBM,  ADAM, 

Imperial- Royal  Prof,  of  Aural  Therap.  in  the  Univ.  of  Vienna. 
A  Text-Book  of  the  Ear  and  its  Diseases.    Translated,  at  the  Author's  re- 
quest, by  James  Patterson  Cassells,  M.  D.,  M.  E.  C.  S.     In  one  handsome  octavo  vol- 
ume of  800  pages,  with  257  original  illustrations.     Cloth,  $5.50. 

The  whole  work  can  be  recommended  as  a  reli-  I  the  practitioner  in  his  treatment.— £o5<cm  Medical 
able  guide  to  the  student,  and  an  efBcient  aid  to  |  and  Surgical  Journal,  June  7, 1883. 


BERRY,  GEORGE  A,,  M.  B.,  F.  R.  C.  S.,  Ed,, 

Ophthalmic  Surgeon,  Edinburgh  Royal  Infirmary. 
Diseases  of  the  Eye.    A  Practical  Treatise  for  Students  of  Ophthalmology.    In 
one  octavo  volume  of  683  pages,  with  .  144    illustrations,  62  of  which  are  beautifully 
colored.     Cloth,  $7.50. 

This  newest  candidate  for  favor  among  ophthal-  novice — with  a  mass  of  details  with  no  key  to  their 
mological  students  is  designed  to  be  purely  clinical  unravelling.  It  is  apparent  that  the  literature  of 
in  character  and  the  plan  is  well  adhered  to.  We  each  subject  has  been  gone  over  in  a  very  thor- 
have  been  forcibly  struck  by  the  rare  good  taste  ough  manner.  The  fact  that  he  was  writing  a 
in  the  selection  of  what  is  essential  which  per-  clinical  treatise  for  beginners  and  not  an  encyclo- 
vades  the  book.  The  author  seems  to  have  the  psedia  has  always  been  present  with  the  author, 
uncommon  faculty  of  viewing  his  subject  as  a  ,  The  number  and  excellence  of  the  colored  illus- 
whole  and  seizing  the  salient  points  and  not  con-  ,  trations  in  the  text  deserve  more  than  a  passing 
fusing  his  reader — presumably  a  student  and  a  ,  notice. — Archives  of  Ophthalmology,  Se.pt.  1889. 


JTJZER,  SEJVRT  E.,  E,  R.  C.  S,, 

Senior  Ass't  Surgeon,  Royal  Westminster  Ophthalmic  Hasp. ;  late  Clinical  Ass't,  Moorflelds,  London. 

A  Handbook  of  Ophthalmic  Science  and  Practice.  Handsome  8vo.  vol- 
ume of  460  pages,  -with  125  woodcuts,  27  colored  plates,  selections  from  Test-types  of 
Jaeger  and  Snellen,  and  Holmgren's  Color-blindness  Test.     Cloth,  $4.50  ;  leather,  $5.50. 

It  presents  to  the  student  concise  descriptions  illustrations  are  nearly  all  original.  We  have  ex- 
and  typical  illustrations  of  all  important  eye affec-  amined  this  entire  work  with  great  care,  and  it 
tions,  placed  in  juxtaposition,  so  as  to  be  grasped  represents  the  commonly  accepted  views  of  ad- 
at  a  glance  Beyond  a  doubt  it  is  the  best  illus-  i  vanced  ophthalmologists.  We  can  most  heartily 
trated  handbook  of  ophthalmic  science  which  has  '  commend  this  book  to  all  medical  students,  prac- 
ever  appeared.    Then,  what  is  still  better,  these    titioners  and  specialists. — Detroit  Lancet,  Jan.  '85. 

NETTLESSIP,  EDWARD,  F.  R.  C.  S., 

Ophthalmic  Surg,  and  Led.  on  Ophth.  Surg,  at  St.  Thomas'  Hospital,  London. 

The  Student's  Guide  to  Diseases  of  the  Eye.  Is'ew  (third)  edition,  thor- 
oughly  revised.  With  a  chapter  on  the  Detection  of  Color-Blindness,  by  Wzlliam 
Thomson,  M.  D.,  Professor  of  Ophthalmology  in  the  Jefferson  Medical  College.  In  one 
12mo.  volume  of  479  pages,  with  164  illust.,  test-types  and  formula.   Cloth,  $2. 

The  extent  of  the  sale  of  this  now  accepted  |  in  the  chapter  devoted  to  operations.  A  very 
authority  has  conclusively  shown  that  its  claim  for  '  important  partof  the  work  to  general  practitioners 
favor  was  not  an  imaginary  one.  The  introductory  i  is  that  embraced  in  the  consideration  of  eye  dis- 
chapter  on  optical  outlines  is  a  wonderfully  clear  eases  in  relation  to  general  diseases  and  condi- 
statement  of  the  principles  involved.  The  writer's  ;  tions.  The  arrangement  of  the  remedies  employed 
decision  of  character  has  fully  impressed  his  pro-  i  into  a  formulary  is  adopted,  and  it  contains  much 
duction,  and  this  is  nowhere  more  apparent  than  [  useful  knowledge.— 6ou</i.  Practitioner,  Dec.  1887. 

NORRIS,  WM.  F.,  M.  D.,  and  OLIVER,  CMAS.  A.,  M.  J). 

Clin.  Prof,  of  Ophthalmology  in  Univ.  of  Pa. 
A  Text-Book  of  Ophthalmology.     In  one  octavo  volume  of  about  500  pages, 
with  illustrations.     Preparing. 

CARTER,  R.  BRVDENELL,  &  FROST,  W.ADAMS, 

F.  R.  C.  S.,  F.  R.  C.  S., 

Ophthalmic  Surgeon  to  and.^  Lect.  on  Ophthal-  AssH  Ophthalmic  Surgeon  and  Joint  Led. 

mic  Surgery  at  St.  George's  Hospital,  London.  on  Oph.  Sur.,  St.  George's  Hasp.,  London. 

Ophthalmic  Surgery.     In  one  12mo.  volume  of  559  pages,  with  91  woodcuts, 

color  blindness  test,  test-types  and  dots  and  appendix  of  formula.      Cloth,  $2.2o.     See 

iSeries  of  Clinical  Manuals,  page  31. 

WELLS  ON  THE  EYE.    In  one  octavo  volume,     i  lAWSON  ON  INJURIES  TO  THE  EYE,  ORBIT 
LAURENCE  AND   MOON'S   HANDY    BOOK   OF  j      ^.ND  EYELIDS:  Their  Immediate  and  Remote 
OPHTHALMIC  SURGERY,  for  the  use  of  Prac-  i      Effects.    In  one  octavo  volume  of  404  pages,  with 
titioners     Second  edition.    In  one  octavo  vol-  |     92  illustrations.    Cloth,  $3.50. 
ume  of  227  pages,  with  65  lUus.    Cloth,  $2.75.     ) 


24     Lea  Brothers  &  Co.'s  Publications — Uriu.  Dis.,  Dentistry,  etc. 
BOBEliTS^WrLLIAJii,  31,  2>., 

Lecturer  on  iledicine  in  the,  Manchester  School  of  yfedicine,  etc. 

A  Practical  Treatise  on  Urinary  and  Renal  Diseases,  including  Uri- 
nary Deposits.  Foiirtli  American  from  the  fourth  London  edition.  In  one  hand- 
some octavo  volume  of  609  pages,  with  81  iUustrations.     Cloth,  $3.50. 

It  mftvbesaid  to  be  the  best  book  in  print  on  the    giiage  in  its  account  of  the  different  affections. — 
subject' of  wiiicli  it  treats. —  The  Americnn  Journal     The  Manche^iter  Medicat  Chronicle,  July,  1885. 
of  the  Medical  Hciences,  Jan.  188G.  The  value  of  this  treatise  as  a  guide  book  to  the 

The  peculiar  value  and  finish  of  the  book  are  in  physician  in  daily  practice  can  hardly  be  over- 
a  measure  derived  from  its  resolute  maintenance  estimated.  That  it  is  fully  up  to  the  level  of  our 
of  a  clinical  and  practical  character.  It  is  an  un-  present  knowledge  is  a  fact  reflecting  great  credit 
rivalled  exposition  of  everything  which  relates  upon  Dr.  Roberts,  who  has  a  wide  reputation  as  a 
directly  or  indirectly  to  the  diagnosis,  prognosis  busy  practitioner. —  The  Medical  Record,  July  31, 
and  treatment  of  urinary  diseases,  and  possesses  I  188G. 
a  completeness  not  found  elsewhere  in  our  Ian-  | 


PUBDY,   CHARLES  TT.,  M,  />.,  Chicago. 

Bright's  Disease  and  Allied  Affections  of  the  Kidneys.  In  one  octavo 
volume  of  288  ])ages,  with  illustrations.     Cloth,  $2. 

The  object  of  this  work  is  to  "  furnish  a  system-  short  space  the  theories,  facts  and  treatments,  and 
atic,  practical  and  concise  description  of  the  going  more  fully  into  their  later  developments, 
pathology  and  treatment  of  the  chief  organic  On  treatment  the  writer  is  particularly  strong, 
diseases  of  the  kidney  associated  with  albuminu-  steering  clear  of  generalities,  and  seldom  omit- 
ria,  which  shall  represent  the  most  recent  ad-  ting,  what  text-booTcs  usually  do,  the  unimportant 
vances  in  our  knowledge  on  these  subjects  ;"  and  items  which  are  all  important  to  the  general  prao- 
this  definition  of  the  object  is  a  fair  description  of  '  titioner. — The  Manchester  Medical  Chronicle,  Oct. 
the  book.    The  work  is  a  useful  one,  giving  in  a  ;  1886. 

MORBIS,  HENRY,  M.  B,,  F,  B.  C,  S., 

Surgeon  to  and  Lecturer  on  Surgery  at  Middlesex  Hospital,  London. 

Surgical  Diseases  of  the  Kidney.  In  one  12mo.  volume  of  554  pages,  with  40 
woodcuts,  and  6  colored  plates.  Limp  cloth,  $2.25.  See  Series  of  Clinical  Manuals,  page  31. 
In  this  manual  we  have  a  distinct  addition  to  I  he  took  in  hand.  It  is  a  full  and  trustworthy 
surgical  literature,  which  gives  information  not  !  book  of  reference,  both  for  students  and  prac- 
elsewhere  to  be  met  with  in  a  single  work.  Such  !  titioners  in  search  of  guidance.  The  ill  ustrationa 
a  book  was  distinctly  required,  and  Mr.  Morris  in  the  text  and  the  chromo-lithographs  are  beau- 
has  very  diligently  and  ably  performed  the  task  ,  tifully  executed. —  The  London  Lancet,  Feb.  26, 1886. 

LUCAS,  CLEMENT,  M.  B,,^.  S,,  E.  R.  C.  S,, 

Senior  Assistant  Surgeon  to  Ouy's  Hospital,  London. 

Diseases  of  the  Urethra.  In  one  12mo.  volume.  Preparing.  See  Series 
of  Clinical  Manuals,  page  4. 

THOMPSON,  SIR  HENRY, 

Surgeon  and  Professor  of  Clinical  Surgery  to  University  College  Hospital,  London. 

Lectures  on  Diseases  of  the  Urinary  Organs.  Second  American  from  the 
third  English  edition.    In  one  8vo.  volume  of  203  pp.,  with  25  illustrations.    Cloth,  $2.25. 

By  the  Same  Author. 
On  the  Pathology  and  Treatment  of  Stricture  of  the  Urethra  and 
Urinary  Fistulse.     From  the  third  English  edition.    In  one  octavo  volume  of  359 
pages,  with  47  cuts  and  3  plates.     Cloth,  $3.50. 

THE  A3IERICAN^YSTEM  OF  DENTISTRY, 

In  Treatises  by  Various  Authors.  Edited  by  Wilbuk  F.  Litch,  M.  D., 
D.  D.  S.,  Professor  of  Prosthetic  Dentistry,  Materia  Medica  and  Therapeutics  in  the 
Pennsylvania  College  of  Dental  Surgery.  In  three  very  handsome  octavo  volumes  con- 
taining 3160  pages,  with  1863  illustrations  and  9  full  page  plates.  Per  volume,  cloth,  $6  ; 
leather,  $7  ;  half  Morocco,  gilt  top,  $8.  The  complete  work  is  now  ready.  For  sale  by 
subscription  only. 

As  an  encyclopaedia  of  Dentistry  it  has  no  su-  '  doubtless  It  is),  to  mark  an  epoch  in  the  history  ol 
perior.  It  should  form  a  part  of  every  dentist's  dentistry.  Dentists  will  be  satisfied  with  it  and 
library,  as  the  information  it  contains  is  of  the    proud  of  it — they  must.    It  is  sure  to  be  precisely 

freatest  value  to  all  engaged  in  the  practice  of  '•  what  the  student  needs  to  put  him  and  keep  him 
entistry. — American  Jour.  Dent.  Sci.,  Sept.  1886.       |  in  the  right  track,  while  tne  profession   at  large 
A  grand  syst«m,  big  enough  and  good  enough    will  receive  incalculable  benefit  from  it.— Odonto- 
and  handsome  enough  for  a  monument  (which  \  graphic  Jou7nal,  J tkU.lSSI. 

COLEMAN,  A.,  L.  R.  C,  B.,  F,  R,  O.  S.,  Exam.  L.  X>.  S., 

Senior  Dent.  Surg,  and  Lect.  on  Dent.  Surg,  at  St.  Bartholomew's  Hosp.  and  the  Dent.  Hosp.,  London. 

A  Manual  of  Dental  Svirgery  and  Pathology.  Thoroughly  revised  and 
adapted  to  the  use  of  American  Students,  by  Thomas  C.  Stellwagen,  M.  A.,  M.  D., 
D.  D.  S.,  Prof,  of  Physiology  in  the  Philadelphia  Dental  College.  In  one  handsome  octavo 
volume  of  412  pages,  with  331  illustrations.     Cloth,  $3.25. 

It  should  be  in  the  possession  of  every  practi-  The  author  brings  to  his  task  a  large  experience 
tioner  in  this  country.  The  part  devoted  to  first  acquired  under  the  most  favorable  circumstances, 
and  second  dentition  and  irregularities  in  the  per-  There  have  been  added  to  the  volume  a  hundred 
manent  teeth  is  fully  worth  the  price.  In  fact,  pages  by  the  American  editor,  embodying  the 
price  should  not  be  considered  in  purchasing  such  views  of  the  leading  home  teachers  in  dental  sur- 
a  work.  If  the  money  put  into  some  of  our  so-  gery.  The  work,  therefore,  may  be  regarded  as 
called  standard  text-books  could  be  converted  into  strictly  abreast  of  the  times,  and  as  a  very  high 
such  publications  as  this,  much  good  would  result,  authority  on  the  subjects  of  which  it  treats. — 
— Southern  Dental  Journal,  May,  1882.  American  Practitioner,  July,  1882. 

BASHAM    ON    RENAL  DISEASES:   A  Clinical    I    one  12mo.  vol.  of  304  pages,  with  21  illustrationa. 
Guide  to  their  Diagnosis  and  Treatment.    In    |    Cloth,  $2.00. 


Lea  Brothers  &  Co.'s  Publications — Venereal,  Impotence.  25 

GBOSS,  SAMUJEL  W.,  A.  31,,  M.  D.,  LL.  JD., 

Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery  in  the  Jefferson  Medical  College  of  Phila. 

A  Practical  Treatise  on  Impotence,  Sterility,  and  Allied  Disorders 
of  the  Male  Sexual  Organs.  New  (4th)  edition,  thoroughly  revised  by  F.  E. 
StTjEGIS,  M.  D.,  Prof,  of  Diseases  of  the  Genito-Urinary  Organs  and  of  Venereal  Diseases, 
N.  Y.  Post  Grad.  Med.  School.  In  one  very  handsome  octavo  volume  of  about  175 
pages,  with  about  20  illustrations.     Preparing. 

A  few  notices  of  the  previous  edition  are  appended. 
_  It  must  be  gratifying  to  both  author  and  pub-  '  This  now  classical  work  on  the  subject  of  impo- 
lishers  that  large  first  and  second  editions  of  this  tence  and  sterility  in  the  male  needs  no  extended 
little  work  were  so  soon  exhausted,  while  the  fact  ;  review,  for  it  is  already  well  known  to  the  pro- 
that  it  has  been  translated  into  Russian  may  indi-  •  fession.  Dr.  Gross  has  by  his  tireless  labor  done 
cate  that  it  filled  a  void  even  in  foreign  literature,  more  towards  clearing  up  the  diagnosis  and  treat- 
His  is  a  careful  and  physiological  study  of  the  i  mentof  these  obscure  cases  than  any  other  Ameri- 
sexual  act,  so  far  as  concerns  the  male,  and  all  can  physician.  The  fact  that  this  book  has  rapidly 
his  conclusions  are  scientifically  reached.  The  run  through  two  large  editions,  and  that  the  author 
book  has  a  place  by  itself  in  our  literature,  and  is  now  forced  to  issue  a  third,  is  good  and  sufficient 
furnishes  a  large  fund  of  information  concerning  evidence  of  its  excellence. — Atlanta  Medical  and 
important  matters  that  are  too  often  passed  over  Surgical  Journal,  April,  1888. 
in  silence. — The  Medical  Press,  June,  1887.  ! 


TAYJLOB,  M.  W.,  A,  M.,  M.  D., 

Surgeon  to  Charity  Hospital,  New   York,  Prof,  of  Venereal  and  Skin  Diseases  in  the  University  of 
Vermont,  Pres.  of  the  Am.  Dermatological  Ass'n. 

The  Pathology  and  Treatment  of  Venereal  Diseases.     Including  the 
results  of  recent  investigations  upon  the  subject.     Being  the  sixth  edition  of  Bumstead 
and  Taylor.      Entirely  rewritten  by  Dr.  Taylor.     Large  8vo.  volume,  about  900  pages, 
with  about  150  engravings,  as  well  as  ■  numerous  chromo-lithographs.     Preparing. 
A  few  notices  of  the  previous  edition  are  appended. 

It  is  a  splendid  record  of  honest  labor,  wide  i  known  that  it  would  be  superfluous  here  to  pass  in 
research,  just  comparison,  careful  scrutiny  and  ■  review  its  general  or  special  points  of  excellence, 
original  experience,  which  will  always-be  held  as  The  verdict  of  the  profession  has  been  passed;  it 
a  high  credit  to  American  medical  literature.  This  •  has  been  accepted  as  the  most  thorough  and  corn- 
Is  not  only  the  best  work  in  the  English  language  plete  exposition  of  the  pathology  and  treatment  of 
upon  the  subjects  of  which  it  treats,  but  also  one  venereal  diseases  in  the  language.  Admirable  as  a 
wnich  has  no  equal  in  other  tongues  for  its  clear,  ,  model  of  clear  description,  an  exponent  of  sound 
comprehensive  and  practical  handling  of  its  ■  pathological  doctrine,  and  a  guide  for  rational  and 
themes.— ^OT.  Jour,  of  the  Med.  Sciences,  Jan,  1884.      successful  treatment,  it  is  an  ornament  to  the  medi- 

Itis  certainly  the  best  single  treatise  on  vene-  cal  literature  of  this  country.  The  additions  made 
real  in  our  own,  and  probably  the  best  in  any  Ian-  ^  to  the  present  edition  are  eminently  judicious, 
gaage.— Boston  Med.  and  Surg.  Journal,  April  3, 188-1.    from  the  standpoint  of  practical  utility.— /ournai  of 

The  character  of  this  standard  work  is  so  well  |  Cutaneous  and  Venereal  D-iseases,  Jan.  1884. 

COJRJVIZ,  F., 

Professor  to  the  Faculty  of  Medicine  of  Paris,  and  Physician  to  the  Lour  cine  Hospital. 

Syphilis,  its  Morbid  Anatomy,  Diagnosis  and  Treatment.  Specially 
revised  by  the  Author,  and  translated  with  notes  and  additions  by  J.  Henry  C.  Simes, 
M.  D.,  Demonstrator  of  Pathological  Histology  in  the  Univ.  of  Pa.,  and  J.  William 
White,  M.  D.,  Lecturer  on  Venereal  Diseases,  Univ.  of  Pa.  In  one  handsome  octavo 
volume  of  461  pages,  with  84  very  beautiful  illustrations.     Cloth,  |3.75. 

The  anatomy,  the  histology,  the  pathology  and  perusal  without  the  feeling  that  his  grasp  of  the 
the  clinical  features  of  syphilis  are  represented  in  wide  and  important  subject  on  which  it  treats  is 
this  work  in  their  best,  most  practical  and  most  :  a  stronger  and  surer  one.— The  London  Practi- 
instructive  form,  and  no  one  will  rise  frorr.  its  i  tioner,  Jan.  1882. 

MUTCSIJ^SOy,  JOl^ATHAN,  F.  B,  S.,  F.  JR,  C.  S., 

Consulting  Surgeon  to  the  London  Hospital. 
Syphilis.     In  one  12mo.  volume  of  542  pages,  with  8  chromo-lithographs.     Cloth, 
$2.25.     See  Series  of  Clinical  Manuals,  page  31. 

Those  who  have  seen  most  of  the  disease  and  i  and  power  of  observation,  but  of  his  patience  and 
those  who  have  felt  the  real  difficulties  of  diagno-  assiduity  in  taking  notes  of  his  cases  and  keep- 
sis  and  treatment  will  most  highly  appreciate  the  ing  them  in  a  form  available  for  such  excellent 
facts  and  suggestions  which  abound  in  these  i  use  as  he  has  put^them  to  in  this  volume.— iyo^cron 
pages.  It  is  a  worthy  and  valuable  record,  not  Medical  Iiecord,No\.  12,  1887. 
only  of  Mr.  Hutchinson's  very  large  experience 


GBOSS,  S.  n.,  M.  !>.,  LL.  J).,  J>.  C,  L.,  etc. 

A  Practical  Treatise  on  the  Diseases,  Injuries  and  Malformations 
of  the  Urinary  Bladder,  the  Prostate  Gland  and  the  Urethra.  Third 
edition,  thoroughly  revised  by  Samuel  W.  Gross,  M.  D.  In  one  octavo  volume  ot  o74 
pages,  with  170  illustrations.     Cloth,  $4.50. 

CVLLFBIEB,  A.,  &  BUMSTEAD,  F.  J.,  M.D.,  LL.B., 

Surgeon  to  the  Hopital  du  Midi.         Late  Professor  of  Venereal  Diseases  in  the  College  of  Physicians 
and  Surgeons,  Neio  I  ork. 

An  Atlas  of  Venereal  Diseases.  Translated  and  edited  by  Freeman  J.  Bum- 
stead  M  D  In  one  imperial  4to.  volume  of  328  pages,  double-columns,  with  26  plates, 
containing  about  150  figures,  beautifoUy  colored,  many  of  them  the  size  of  lile.  btrongly 
bound  in  cloth,  $17.00.    A  specimen  of  the  plates  and  text  sent  by  mail,  on  receipt  of  2o  cts. 

LEE'S   LECTURES  ON   SYPHILIS  AND   SOME  ;  TION.    In  one  8vo.  vol.  of  246  pages.    Cloth,  82.25. 


28 


Lea  Brothers  &  Co.'s  Publications — Dis.  of  Women,  Midwfy. 


EMMET,  TH03IAS  ADDIS,  M,  D.,  LL.  D., 

Surgeon  to  the  Wovian's  Hospital,  Xeio  York,  etc. 

The  Principles  and  Practice  of  Gynaecology ;  For  the  use  of  Students  and 
Practitioners  of  Medicine.  New  (tiiinl)  edition,  thoroughly  revised.  In  one  large  and  very 
handsome  octavo  vohime  of  880  pages,  with  150  illustrations.  Cloth,  $5 ;  leather,  $6; 
very  handsome  half  Russia,  raised  bands,  $6.50. 

We  are  in  doubt  whether  to  congratulate  the  ,  the  privilege  thus  offered  them  of  perusing  the 
Ruthor  more  than  the  profession  upon  the  appear-  riews  and  practice  of  the  author.  His  earnestness 
»nce  of  the  third  edition  of  this  well-known  work.  :  of  purpose  and  conscientiousness  are  manifest. 
Embodying,  as  it  does,  the  life-long  experience  of  j  He  gives  not  only  his  individual  experience  but 
one  who  ha-s  conspicuously  distinguished  himself  endeavors  to  represent  the  actual  state  of  gynse- 
as  a  bold  and  successful  operator,  and  who  has  ;  cological  science  and  art. — British  yiedical  Jour- 
devoted  so  much  attention  to  the  specialty,  we  i  nal,  May  16, 1885. 
feel  sure  the  profession  will  not  fail  to  appreciate  i 


TAIT,  LAWSON,  JF.B.  C.  S., 

Professor  nf  Oynctcology  in  Queen's   CoUege,  Birmingham ;  late  President  of  the  British  Gyne- 
cological Society ;  Fellow  American  Gynecological  Society. 

Diseases  of  Women  and  Abdominal  Surgery.  In  two  very  handsome 
octavo  volumes.  Vohime  I.,  554  pages,  62  engravings  and  3  plates.  Cloth,  $3.  Just 
ready.     Volume  II.,  preparing. 

The  plan  of  the  work  does  not  indicate  the  regu-  Much  of  the  text  is  abundantly  illustrated  with 

lar  system  of  a  text  book,  and  yet  nearly  every-  cases,  which  add  value  in  showing  the  results  of 

thing  of  disease  perlaining  to  the  various  orsrans  the  suggesteil  plans  of  treatment.    We  feel  con- 

reeeives  a  fair  consideration.    The  description  of  fident  that  few  trynecologista  of  the  country  will 

diseased  conditions  is  exceedingly  clear,  and  the  fall   to  p'ane  the"  work    in   their    libraries. — The 

treatment,  medical  or  surgical,  is  very  satisfactory.  Obstetric  Gazette,  March,  1890. 


DAVENPOnT,  F.   H.,  31.   D., 

Astistant  in  Gynaecology  in  the  Medical  Department  of  Harvard  Universitu,  Boston. 

Diseases  of  Women,  a  Manual  of  Non-Surgical  Gynaecology.  De- 
signed especially  for  the  Use  of  Students  and  General  Practitioners.  In  one  handsome 
12mo.  volume  of  317  pages,  with  105  illustrations.     Cloth,  $1.50.     Just  ready. 


We  agree  with  the  many  reviewers  whose  no- 
tices we  have  read  in  other  journals  congratulating 
Dr.  Davenport  on  the  success  which  he  has 
attained.  He  has  tried  to  write  a  book  for  the 
student  and  general  practitioner  which  would 
tell  them  just  what  they  ought  to  know  without 
distracting  their  attention  with  a  lot  of  compila- 
tions for  which  they  could  have  no  possible  use. 
In  this  he  has  been  eminently  successful.  There 
is   not    even    a   paragraph    of    useless    matter. 


Everything  is  of  the  newest,  freshest  and  most 
practical,  so  much  so  that  we  have  recommended 
it  to  our  class  of  gynecology  students.  What  the 
author  advises  in  the  way  of  treatment  has  all 
been  practically  tested  by  himself,  and  each 
method  receives  only  so  much  commendation  as  he 
has  found  that  it  "deserves.  We  ate  sure  that 
these  good  qualities  will  command  for  it  a  large 
sale. — Canada  Medical  Record,  Dee.  1889. 


MAT,    CHARLES  S.,  31.   D., 

Late  House  Surgeon  to  Mount  Sinai  Hospital,  New  York. 
A  Manual  of  theDiseases  of  Women.   Being  a  concise  and  systematic  expo- 
sition of  the  theory  and  practice  of  gynecology.      New  (2d}  edition,  edited  by  L.  S.  Rau, 
M.  D.,  Attending  Gynecologist  at  the  Harlem  Hospital,  X.  Y.     In  one   12mo.  volume  oi 
360  page?,  with  31  illustrations.     Cloth,  $1.75.     Just  ready. 


This  is  a  manual  of  gynecology  in  a  very  con- 
densed form,  and  the  fact  that  a  second  edition 
has  been  called  for  indicates  that  it  has  met  with 
a  favorable  reception.  It  is  intended,  the  author 
tells  us,  to  aid  the  student  who  after  having  care- 
fully perused  larger  works  desires  to  review  the 
subject,  and  he  add?  that  it  may  be  useful  to  the 
practitioner  who  wishes  to  refresh  his  memory 


rapidly  but  has  not  the  time  to  consult  larger 
works.  We  are  much  struck  with  the  readiness 
and  convenience  with  which  one  can  refer  to  any 
subject  contained  in  this  volume.  Carefully  com- 
piled indexes  and  ample  illustrations  also  enrich 
the  work.  This  manual  will  be  found  to  fulfil  its 
purposes  very  satisfactorily. —  The  Physician  and 
Surgeon,  June,  1890. 


DVNCAN,  J.  MATTHEWS,  M.JD.,  LL.  H.,  F.  B.  S.  E.,  etc. 

Clinical  Lectures  on  the  Diseases  of  Women ;  Delivered   in  Saint  Bar- 
tholomew's Hospital.     In  one  handsome  octavo  volume  of  175  pages.     Cloth,  $1.50. 

They  are  in  every  way  worthy  of  their  author  ;  rule,  adequately  handled  in  the  textrbooks;  others 
Indeed,  we  look  upon  them  as  among  the  most  of  them,  while  bearing  upon  topics  that  are  usually 
valuable  of  his  contributions.  They  are  all  upon  treated  of  at  length  in  such  works,  yet  bear  such  A 
matters  of  great  interest  to  the  general  practitioner,  stamp  of  individuality  that  they  deserve  to  be 
Some  of  them  deal  with  subjects  that  are  not,  as  a    widely  read.— A'.  Y.  Medical  Journal,  March,  1880. 


HODGE  ON  DI.SEASE5  PECULIAR  TO  WOMEN. 
Including  Displacements  of  the  Uterus.  Second 
edition,  revised  and  enlarged.  In  one  beauti- 
fully printed  octavo  volume  of  519  pages,  with 
original  illustrations.    Cloth,  S1.50 

R.\MSBOTHAMS  PRINCIPLES  AND  PRAC- 
TICE OF  OBSTETRIC  MEDICINE  AND 
SURijERY.  In  reference  to  the  Process  of 
Parturition.  A  new  and  enlarged  edition,  thor- 
oughly revised  by  the  Author.  With  additions 
by  W.  V.  KEiT.XG,  M.  D  ,  Profes.sor  of  Obstetrics, 


etc.,  in  the  Jefferson  Medical  College  of  Phila- 
delphia. In  one  large  and  handsome  imperial 
octavo  volume  of  tUO  pages,  with  iH  full  page 
plates  and  43  woodcuts  in  the  text,  containing  in 
all  nearly  200  beautiful  figures.  Strongly  bound 
in  leather,  with  raised  bands,  ?7. 
WESTS  LECTURES  ON  THE  DISEASES  OF 
WOMEN  Third  American  from  the  third  Lon- 
don edition.  In  one  octavo  volume  of  543  pages. 
Cloth,  .•53.75;  leather,  $1.75. 


Lea  Brothers  &  Co.'s  Publications — ]>Ildwifery. 


29 


BLATFAIR,  W.  S.,  M.  D.,  F.  B.  C.  P., 

Professor  of  Obstetric  Medicine  in  King's  College,  London,  etc. 

A  Treatise  on  the  Science  and  Practice  of  Midwifery.  New  (fifth) 
American,  from  the  seventh  English  edition.  Edited,  with  additions,  by  Egbert  P.  Hae- 
Eis,  M.  D.  In  one  handsome  octavo  volume  of  664  pages,  with  207  engravings  and  5 
plates.     Qoth,  $4.00 ;  leather,  85.00.     Just  ready. 

Playfair's  Midioif&ry  has  for  many  years  been  a  [  is  perhaps  the  most  popular  work  of  its  kind  ever 
favorite  authority  both  among  obstetric  teachers  '  presented  to  the  profession.  Beginning  with  the 
and  general  practitioners  of  tne  obstetric  art.  A  ,  anatomy  and  physiology  of  the  organs  concerned, 
work  of  this  kind  having  reached  a  fifth  .American  i  notliing  is  left  unwritten  that  the  practical  ac- 
from  the  seventh  English  edition  would  seem  '  coucheur  should  know.  It  seems  that  every 
scarcely  to  require  any  extended  notice.  Of  [  conceivable  physiological  or  pathological  condi- 
previous  American  editions  the  matter  has  been  j  tion  from  the  moment  of  conception  to  the  time 
largely  rewritten    or   remodelled,  besides  many  |  of    complete    involution    has    had   the   author's 

patient  attention.  The  plates  and  illustrations, 
carefully  studied,  will  teach  the  science  of  mid- 
wifery. The  reader  of  this  book  will  have  before 
him  the  very  latest  and  best  of  obstetric  practice, 
and  also  of  all  the  coincident  troubles  connected 
therewith. — Southern  Practitioner,  Dec,  1889. 


new  short  notes  have  been  added.  For  either  the 
student  or  the  old  practitioner  this  work  meets 
all  needs;  it  is  fall  and  yet  condensed  ;  it  is  clear 
and  well  arranged.— Obsiefric  Gazette,  Nov.,  1889. 

Truly  a  wonderful  book;  an  epitome  of  all  ob- 
stetrical knowledge,  full,  clear  and  concise.  In 
thirteen  years  it  has  reached  seven  editions.    It 


KTNG,  A,  F,  A,,  M.  J)., 

Professor  of  Obstetrics  and  Diseases  of  Women  in  the  Medical  Department  of  the  Columbian  Univer- 
sity, Washington,  D.  C,  and  in  the  University  of  Vermont,  etc. 

A  Manual  of  Obstetrics.     Kew  (fourth)  edition.     In  one  very  handsome  12mo. 
volume  of  432  pages,  with  140  illustrations.     Cloth,  $2.50.     Just  ready. 

Dr.  King,  in  the  preface  to  the  first  edition  of  I  the  description  of  labor,  both  normal  and  abnor- 
this  manual,  modestly  states  that  "its  purpose  is  mal,  that  Dr.  King  is  at  his  best.  Here  his  style 
to  furnish  a  good  groundwork  to  the  student  at  |  is  so  concise,  and  the  illustrations  are  so  good, 
the  beginning  of  his  obstetric  studies."  Its  pur-  !  that  the  veriest  tyro  could  not  fail  to  receive  a  clear 
pose  is  attained;  it  will  furnish  a  good  ground-  I  conception  of  labor,  its  complications  and  treat- 
work  to  the  student  who  carefully  reads  it;  and  |  ment.  Of  the  141  illustrations  it  may  be  safely 
further,  the  busy  practitioner  should  not  scorn  the  ;  said  that  they  all  illustrate,  and  that  the  engraver's 
volume  because  written  for  students,  as  it  con-  ]  work  is  excellent.  The  name  of  the  publishers 
tains  much  valu»ble  obstetric  knowledge,  some  \  is  a  sufficient  guarantee  that  the  work  is  pre- 
of  which  is  not  found  in  more  elaborate  text-  i  sented  in  an  attractive  form,  and  from  every 
books.  The  chapters  on  the  anatomy  of  the  '  standpoint  we  can  most  heartily  recommend  the 
female  generative  organs,  menstruation.'^fecunda-  •  book  both  to  practitioner  and  student. — The  Medir 
tion,  the  signs  of  pregnancy,  and  the  diseases  of  ,  cal  News,  Dec.  7, 1S89. 
pregnancy,  are  all  excellent  and  clear;  but  it  is  in  i 


BAHJSTES,  BOBEMT,  31.  D.,   and   FAWCOJTBT,  M,  I),, 

Phys.  to  the  General  Lying-in  Hosp.,  Lond.  Obstetric  Phys.  to  St.  Thomas'  Hosp.,  Lond. 

A  System  of  Obstetric  Medicine  and  Surgery,  Theoretical  and  Clin- 
ical. For  the  Student  and  the  Practitioner.  The  Section  on  Embryology  by  Prof.  Milnes 
Marshall.  In  one  8vo.  volume  of  872  pp.,  with  231  illustrations.  Cloth,  -$o ;  leather,  $6. 
The  immediate  purpose  of  the  work  is  to  furnish  j  the  best  obstetrical  opinions  of  the  time  in 


a  handbook  of  obstetric  medicine  and  surgery 
for  the  use  of  the  student  and  practitioner.  It  is 
not  an  exaggeration  to  say  of  the  book  that  it  is 
the  best  treatise  in  the  English  language  yet 
published,  and  this  will  not  be  a  surprise  to  those 
who  are  acquainted  with  the  work  of  the  elder 
Barnes.     Every  practitioner  who  desires  to  have 


readily  accessible  and  condensed  form,  ought  to 
own  a  copy  of  the  book. — Journal  of  the  American 
Meiiical  Association,  June  12,  1S86. 

The  Authors  have  made  a  text- book  which  is  in 
every  way  quite  worthy  to  take  a  place  beside  the 
best  treatises  of  the  period.— iVew  York  Medical 
Journal,  July  2,  1SS7. 


BABVIW,  TSEOFSILVS,  M.  !>.,  LL.  J>., 

Prof,  of  Obstetrics  and  the  Diseases  of  Women  and  Children  in  Jefferson  Med.  Coll.,  Phila. 

The  Science  and  Art  of  Obstetrics,    ^"ew  (2d)  edition.    In  one  handsome 
8vo.  volume  of  about  700  pages,  with  about  225  engravings  and  a  colored  plate.   Shortly. 

BABKFB,  FOBDTCF,  A.  M.,  M.  2).,  LL,  L>.  Fdin., 

Clinical  Professor  of  Midwifery  and  the  Diseases  of  Women  in  the  Bellevue  Hospital  Medical  College, 
New  York,  Honorary  Fellow  of  the  Obstetrical  Societies  of  London  and  Edinburgh,  etc.,  etc. 

Obstetrical  and  Clinical  Essays.    12mo.,  about  300  pages.    Preparing. 
PABBY,  JOJBLJS  S.,  M.  D.] 

Obstetrician  to  the  Philadelphia  Hospital,  Vice-President  of  the  Obstet.  Society  of  Philadelphia. 
Extra  -  Uterine  Pregnancy:  Its   Clinical  History,   Diagnosis,   Prognosis  and 
Treatment.     In  one  handsome  octavo  volume  of  272  pages.     Cloth,  $2.50. 


WINCKEL.F.  ^   .^x,,^v,^ 

A  Complete  Treatise  on  the  Pathology  and  Treatment  of  Childbed, 

For  Students  and  Practitioners.     Translated,  with  the  consent  of  the  Author,  from  the 
second  German  edition,  bv  J.  K.  Chadwick,  M.  D.    Octavo  484  pages.    Cloth,  $4.00. 


ASHWELL'S  PRACTICAL  TREATISE  ON  THE 
DISEASES  PECULIAR  TO  WOMEN.  Third 
American  from  the  third  and  revised  London 
edition.    In  one  8vo.  vol.,  pp.  520.    Cloth,  83.50. 

TANNER  ON  PREGNANCY.  Octavo,  490  pages, 
colored  plates.  16  cuts.    Cloth,  S4.2o. 


CHURCHILL  ON  THE  PUERPERAL  EEVER 
AND  OTHER  DISE.A.SES  PECULIAR  TO  WO- 
MEN.    In  one  8vo.  vol.  of  464  pages.    Cloth,  82.50. 

MEIGS  ON  THE  NATURE,  SIGNS  AND  TREAT- 
MENT  OF  CHILDBED  FEVER.  In  one  8vo. 
volume  of  346  pages.    Cloth,  82.00. 


30  Lea  Brothers  &  Co.'s  Publications — Midwfy.,  Dis.  Ghildn. 

LEISHMAN,  WILLIAM,  M.  JD., 

Regius  Professor  of  Midwifery  in  the  University  of  Olasgoxc,  etc. 

A  System  of  Midwifery,  Including  the  Diseases  of  Pregnancy  and  the 
Puerperal  State.  Third  American  edition,  revised  by  llie  Author,  with  additions  by 
John  S.  Parry,  M.  D.,  Obstetrician  to  the  Phihulelphia  Hospital,  etc.  In  one  large  and 
very  handsome  octavo  volume  of  740  paces,  with  205  illustrations.  Cloth,  $4.50 ;  leather, 
$5.50. 

The  author  Is  broad  in  his  teachings,  and  dis-  1  must  prove  admirably  adapted.  Complete  in  all  its 
cusses  briefly  the  comparative  anatomy  of  the  pel-  parts,  essentially  modern  in  its  teachings,  and  with 
vis  and  the  mobility  of  the  pelvic  articulations,  demonstrations  noted  for  clearness  and  precision, 
The  second  chapter  is  devoted  especially  to  it  will  gain  in  favor  and  be  recognized  as  a  worli 
the  study  of  the  pelvis,  while  in  the  third  the  of  standard  merit.  The  work  cannot  fail  to  be 
female  organs  of  generation  are  introduced,  popular  and  is  cordially  recommended. — N.  O. 
The  structure  and  development  of  the  ovum  are  [  Med.  and  Surg.  Journ.,  March.  18S0. 
admirably  described.  Then  follow  chapters  upon  I  It  has  been  well  and  carefully  written.  The 
the  various  subjects  embraced  in  the  study  of  mid-  :  views  of  the  author  are  broad  and  liberal,  and  in- 
wifery.  The  descriptions  tliroughout  the  work  are  dicate  a  well-balanced  judgment  and  matured 
plain  aiid  pleasing.  It  is  sufficient  to  state  that  in  mind.  We  observe  no  spirit  of  dogmatism,  but 
this,  the  last  edition  of  this  well-known  work, every  the  earnest  teaching  of  the  thoughtful  observer 
recent  advancement  in  this  field  has  been  brought  and  lover  of  true  science.  Take  the  volume  as  k 
forward.— P/iviifian  and  Surgeon,  Jan.  1S80.  whole,  and  it  has  few  eqneXs.— Maryland  Medical 

To   the  American   student   the  work   before  us    Journal,  Feb.  1880. 

LANDIS,  HENRY  G.,  A,  M,,  M,  2>., 

Professor  of  Obstetrics  and  the  Diseases  of  Wo7nen  in  Starling  Medical  College,  Columbus,  O. 

The  Management  of  Labor,  and  of  the   Lying-in  Period.     In  one 

handsome  12mo.  volume  of  334  pages,  with  28  illustrations.     Cloth,  $1.75. 

The  author  has  designed  to  place  in  the  hands  tempt  any  one  who  should  happen  to  commence 
of  the  young  practitioner  a  book  in  which  he  can  the  book  to  read  it  through.  The  author  pre- 
find  necessary  information  in  an  instant.  As  far  supposes  a  theoretical  knowledge  of  obstetrics, 
as  we  can  see,  nothing  is  omitted.  The  advice  is  and  has  consistently  excluded  from  this  little 
sound,  and  the  proceedures  are  safe  and  practical,  work  everything  that  is  not  of  practical  use  in  the 
Ctntralbtatt  fur  Oynakologie,  December  4,  1886.  lying-in  room.     We  think  that  if  it  is  as  widoly 

This  is  a  book   we  can   heartily  recommend.  \  read  as  it  deserves,  it  will   do  much  to  improve 
the  author  goes  much  more  practically  into  the    obstetric  practice  in  general. — New  Orleans  Medi- 
details  of  the  management  of  labor  than  most  I  cal  and  Surgical  Journal,  Liar.  1886. 
text-books,  and  is  so  readable  throughout  as  to  | 


SMITH,  J.  LEWIS,  31,  D., 

Clinical  Professor  of  Diseases  of  Children  in  the  Bellevue  Hospital  Medical  College,  N.  Y. 

A  Treatise  on  the  Diseases  of  Infancy  and  Childhood.  New  (sixth) 
edition,  thoroughly  revised  and  rewritten.  In  one  handsome  octavo  volume  of  867 
pages,  with  40  illustrations.     Cloth,  $4.50 ;  leather,  $5.50. 

For  years  it  has  stood  high  in  the  confidence  of 
the  profession,  and  with  the  additions  and  alter- 
ations now  made  it  may  be  said  to  be  the  best 


book  in  the  language  on  the  subject  of  which  it 
treats.  An  examination  of  the  text  fully  sus- 
tains the  claims  made  in  the  preface,  that  "in 
preparing  the  sixth  edition  the  author  has  revised 
the  text  to  such  an  extent  that  a  considerable 


will  readily  recognize  the  painstaking  with  which 
this  revision  has  been  made.  Many  of  the  articles 
have  been  entirely  rewritten.  The  whole  work  is 
enriched  with  a  research  and  reasoning  which 
plainly  show  that  the  author  has  spared  neither 
time  nor  labor  in  bringing  it  to  its  present  ap- 
proach towards  perfection.  The  extended  table  of 
contents  and  the  well-prepared  index  will  enable 


part  of  the  tiook  may  be  considered  new."  If  the  |  the  busy  practitioner  to  reach  readily  and  quickly 
young  practitioner  proposes  to  place  in  his  library  :  for  reference  the  various  subjects  treated  of  in  the 
but  one  book  on  the  diseases  of  children,  we  |  body  of  the  work,  and  even  those  who  are  familiar 
would  unhesitatingly  say,  let  that  book  be  the  one  ;  with  former  editions  will  find  the  improvement* 
which  is  the  subject  of  this  notice.— TTie  American  \  in  the  present  richly  worth  the  cost  of  the  work. — 
Juurnat  of  the  Molical  Sciences,  April,  188C.  I  AtUinta  Medical  and  Surgical  Journal,  Dec.  18815. 

No  better  work  on  children's  diseases  could  be  Dr.  Smith's  work  ha"  justly  become  the  standard 
placed  in  the  hands  of  the  student,  containing,  as  '  all  over  the  world  as  the  book  on  children's  dis- 
It  does,  a  very  complete  account  of  the  symptoms  eases  The  whole  book  is  admirable,  both  for  the 
and  pathology  of  the  disea-ses  of  early  life,  and  practitioner  and  the  student.  Dr.  Smith  writes 
possessing  the  further  advantage,  in  which  it  from  a  large  experience  and  a  close  observation 
stands  alone  amongst  other  works  on  its  subject,  of  cases  at  the  bedside.  He  is  extremely  prao- 
of  recommending  treatment  in  accordance  with  tical,  and  these  facts  make  the  work  what  it  ia — 
the  most  recent  therapeutical  views.— British  and  ,  the  best  of  all  works  on  the  diseases  of  children. 
Foreign  Medico-Chirurgical  Review.  —Virginia  Medical  Monthly,  June,  1886. 

Those  familiar  with  former  editions  of  the  work 


OWEN,  EDMUND,  31  B.,  F.  B,  C  S,, 

Surgeon  to  the  Children's  Hospital,  Oreat  Ormond  St.,  London. 

Surgical  Diseases  of  Children.  In  one  12mo.  volume  of  525  pages,  with  4 
chromo-lithographic  plates  and  85  woodcuts.  Cloth,  $2.  See  Series  of  Clinical  Manuals, 
page  31. 

One  is  immediately  struck  on  reading  this  book    honestly    recommended    to    both    students    and 
with  its  agreeable  style  and  the  evidence  it  every-    practitioners.      It  is  full  of  sound   information, 
where  presents  of  the  practical   familiarity  of  its  i  pleasantly  given.— Annals  of  Surgery,  May,  1886. 
author   with    his    subject.      The    book    may   be  | 

WEST,  CHABLES,  31.  D., 

Physician  to  the  Hospital  for  Sick  Children,  London,  etc. 

On  Some  Disorders  of  the  Nervous  System  in  Childhood.  In  one  small 
12mo.  volume  of  127  pages.     Cloth,  81.00. 

CONDIE'S    PRACTICAL   TREATISE    OK    THE    I    vised  and  augmented.    In  one  octavo  volume  of 
DISEASES  OF  CHILDREN.    Sixth  edition,  re-    |    779  pages.    Cloth.  85.25;  leather,  86.26. 


Lea  Brothers  &  Co.'s  Publications — Med.  Juris.,  ]>Iiscel,  31 


TIDY,  CBLAMLESMETMOTT,  M.  B.,  F.  C.  S., 

Professor  of  Chemistry  and  of  Forensic  Medicine  and  Public  Health  at  the  London  Hospital,  etc. 

Legal  Medicine.  Volume  II.  Legitimacy  and  Paternity,  Pregnancy,  Abor- 
tion, Kape,  Indecent  Exposure,  Sodomy,  Bestiality,  Live  Birth,  Infanticide,  Asphyxia, 
Drowning,  Hanging,  Strangulation,  Suffocation.  Making  a  very  handsome  imperial  oc- 
tavo volume  of  529  pages.     Cloth,  $6.00 ;  leather,  $7.00. 

Volume  I.  Containing  664  imperial  octavo  pages,  with  two  beautiful  colored 
plates.     Cloth,  $6.00 ;  leather,  $7.00. 

The  satisfaction  expressed  with  the  first  portion  i  tables  of  cases  appended  to  each  division  of  the 
of  this  work  is  in  no  wise  lessened  by  a  perusal  of  j  subject  must  have  cost  the  author  a  prodigious 
the  second  volume.  We  find  it  characterized  by  amount  of  labor  and  research,  but  they  constitute 
the  same  fulness  of  detail  and  clearness  of  ex-  one  of  the  most  valuable  features  of  the  book, 
pression  which  we  had  occasion  so  highly  to  com-  |  especially  for  reference  in  medico-legal  trials. — 
mend  in  our  former  notice,  and  which  render  it  so  American  Journal  of  the  Medical  Sciences,  April,  1884. 
valuable    to    the   medical    jurist.      The    copious  ; 


TAYLOB,  ALFJEtBD  S.,  W,  !>., 

Lecturer  on  Medical  Jurisprudence  and  Chem^istry  in  Chuy's  Hospital,  London. 

Poisons  in  Relation  to  Medical  Jurisprudence  and  Medicine.  Third 
American,  from  the  third  and  revised  English  edition.  In  one  large  octavo  volume  of  788 
pages.     Cloth,  $5.50 ;  leather,  $6.50. 


By  the  Same  Author. 
A  Manual  of  Medical  Jurisprudence.     Eighth  American  from  the  tenth  Lon- 
don edition,  thoroughly  revised  and  rewritten.     Edited  by  John  J.  Eeese,  M.  D.     In  one 
large  octavo  volume. 

I*FJPJPFIt,  AUGUSTUS  J.,  M.  S,,  M.  B.,  F.  It,  C.  S., 

Examiner  in  Forensic  Medicine  at  the  University  of  London. 
Forensic  Medicine.    In  one  pocket-size  12mo.  volume.    Preparing.    See  Students^ 
Series  of  ManuaU,  below. 

STUDENTS'  SEMIES  OF  MAIfUALS. 

A  Series  of  Fifteen  Manuals,  for  the  use  of  Students  and  Practitioners  of  Medicine  and  Surgery, 
written  by  eminent  Teachers  or  Examiners,  and  issued  in  pocket-size  12mo  volumes  of  300-540  pages, 
richly  illustrated  and  at  a  low  price.  The  following  volumes  are  now  ready:  Teeves'  Manual  of  Sur- 
gery, by  various  writers,  in  ihree  volumes,  each,  S2;  Beli/s  Comparative  Physio  ogy  and  Anatomy,  S2; 
G-ould's  Surgical  Diagnosis.  82 ;  Robertson's  Physiological  Physics,  $2 ;  BRrcE's  Materia  Medica  and  Thera- 
peutics (4th  edition),  §1.50;  Power's  Human" Physiology  (2d  edition),  §1.50;  Claeee  and  Lockwood's 
Dissectors'  Manual,  Sl.50;  Raxfe's  Clinical  Chem'stry,  §1.50;  Treves'  Surgical  Applied  Anatomy,  $2; 
Pepper's  Surgical  Pathology,  §2;  and  Klein's  Element'^  of  Histology  (4th  edition),  §1.75.  The  following 
is  in  press  :    Peppee's  Forensic  Medicine.    For  separate  notices  see  index  on  last  page. 


SEMIES  OF  CLINICAL  MANUALS. 

In  arranging  for  this  Series  it  has  been  the  design  of  the  publishers  to  provide  the  profession  with 
a  collection  of  authoritative  monographs  on  important  clinical  subjects  in  a  cheap  and  portable  form. 
The  volumes  will  contain  about  5.50  pages  and  will  be  freely  illustrated  by  chromo-lithographs  and  wood- 
cuts. The  following  volumes  are  now  ready :  Ys.o  on  Food  in  Health  and  Disease,  $2;  IBroadbent  on 
the  Pulse.  $1.75;  Caetee  &  Feost's  Ophthalmic  Surgery,  §2.25;  Hutchinson  on  Syphilis,  $2.25;  Ball  on 
the  Rectum  and  Anus,  §2.25;  Marsh  on  the  .Joints,  §2;  Owen  on  Surgical  Diseases  of  Children,  §2; 
MoEEis  on  Surgical  Diseases  of  the  Kidney,  $2.25;  Pick  on  Fractures  and  Dislocations,  $2;  Butlin  on 
the  Tongue,  §;3.5b;  Teeves  on  Intestinal  Obstruction,  §2;  and  Savage  on  Insanity  and  Allied  Neuroses,  §2. 
The  following  is  in  active  preparation:  Lucas  on  Diseases  of  the  Urethra.  For  separate  notices  see 
index  on  last  page. 

LEAfSENBYC. 

Chapters  from  the  Religious  History  of  Spain. — Censorship  of  th© 
Press. — Mystics  and  Illuminati. — The  Endemoniadas  of  Queretaro. — 
El  Santo  Nino  de  la  Guardia. — Brianda  de  Bardaxi.  In  one  12mo.  volume 
of  about  500  pages.     In  press. 

In  making  researches  for  a  History  of  the  Spanish  Inquisition  the  author  has  been 
led  to  investigate  various  subjects  deserving  of  treatment  more  elaborate  than  could  be 
accorded  to  them  in  a  continuous  narrative.  These  he  has  worked  out  in  the  present  vol- 
ume in  the  hope  that  beside  the  intrinsic  interest  of  the  themes  themselves,  they  may 
serve  to  explain  some  of  the  causes  which  reduced  to  impotence  a  nation  ttat  in  the 
sixteenth  century  aspired  to  universal  monarchy. 

By  the  same  Author. 
Superstition  and  Force :  Essays  on  The  Wager  of  Law,  The  Wager  of 
Battle,    The  Ordeal  and  Torture.     Third  revised  and  enlarged  edition.     In  one 
handsome  royal  12mo.  volume  of  552  pages.     Cloth,  $2.50. 

By  the  Same  Author. 
Studies  in  Church  History.    The  Rise  of  the  Temporal  Power— Ben- 
efit of  Clergy— Excommunication.     New  edition.     In  one  very  handsome  royal 
octavo  volume  of  605  pages.     Cloth,  $2.50. 


Allen's  Anatomy  .....        6 

American  Journal  of  tlie  Medical  Sciences  3 

American  Systems  of  (iynecoloKV  and  Obstetrics     27 
American  System  of  I'ractical  Medicine .  .       15 

American  System  of  Dentistry       -  .  ,24 

Aslihursl's  snrgery       .  .  .  .  .20' 

Asluvell  on  Diseases  of  Women       .  .  .29 

Atttield's  Chemistry       ....  9 

Ball  on  the  Rectum  and  Anus  .  .  .20,31 

Barker's  Obstetrical  and  Clinical  JEssays,  .        29 

Barlow's  Practice  of  Medicine  .  .  .        17 

Barnes'  System  ol  Obstetric  Medicine       .  .       29 

Bartliolow  on  Klectricity       .  .  .  .       17  , 

Baaham  on  Renal  Dlseafies    ....       24 

Bell's  Comparative  Physiology  and  Anatomy  .    7,  31 
Bellamy's  Surgical  Anatomy  ...         6 

Berry  on  the  Eye  .....       23 

BilliiiKs' Natioiial  Medical  Dictionary     .  .         4 

Blandford  on  Insanity  ....       19 

Blo.Tam's  Chemistry      .....        9 

Bristowe's  Practlce'of  Medicine      ...       14 
Broadbent  on  the  Putse  .  .  .  .18,31 

Browne  on  the  Throat,  Nose  and  Ear       .  .       18 

Bruce's  Jlateria  Medica  and  Therapeutics         .        12 
Brunton's  Materia  Meilica  and  Therapeutics     .       II 
Brj-ant's  Practice  of  Surgery  .  .  .  .21 

Bumstead  iuul  Taylor  on  Venereal.    See  Taylor.     25 
Burnett  on  the  Ear         .....       23 

Butlin  on  the  Tongue    ....  .21,31 

Carpenter  on  the  Use  and  Abuse  of  Alcohol      .         8 
Carpenter's  Human  Physiologv      .  .  .         S 

Carter  &  Frost's  Ophthalmic  Stirgery       .  .23,31 

Chambers  on  Diet  and  Regimen      ...       17 
Chapman's  Human  Phvsiologv       ...         8 
Charles'  Physiological  and  Pathological  Chem.       10 
Churchill  on  Puerperal  Fever  .  .  .        29 

Clarke  and  Dock  wood's  Dissectors' Manual       .    6,31 
Classen's  Quantitative  Analysis      ...       10 
Cleland's  Dissector        .  ....         6 

Clouston  on  Insanity    .  .  .  ,  .19 

Clowes'  Practical  Chemistry  .  .  .10 

Coats'  Patliolog%-  .  .  .  .  .13 

Cohen  on  the  Tfiroat     .  .  .  .  .18 

Coleman's  Dental  Surgerv     .  .  .  .24 

Condle  on  Diseases  of  Chfldren        ...       30 
Coruil  on  Syphilis  .....       25 

Dalton  on  the  Circulation       ....        7 

Dallon's  HumanPhvsiology  ...         8 

Davenport  on  ]iise;ises  of  Women  .  .  .       28 

Davis' Clinical  Lecturfg  ...        17 

Draper's  Medical  Phvsics       ....         7 

Druitt's  Modern  Surgery         ....        20 

Duncan  on  Diseases  of '\Vomen        .  .  .28 

Dungllson's  Meilical  Dictionary      ...         5 
Edes' Materia  Medica  and  Therapeutics  .       12 

Edis  on  Diseases  of  Women    ....       27 

Ellis' Demonstrations  of  Anatomy  .  .         7 

Emmet's  Gynaecology  .  .  .       28 

Erlchsen's  System  of  Surgery  ...       21 

Farquharson's  Therapeutics  and  Mat.  Med.       .       12 
Fenwick's  Metlical  Diagnosis  ...       16 

Finlayson's  Clinical  Diagnosis         .  .  .16 

Flint  on  Auscultation  and  Percussion       .  .       18 

Flint  on  Phthisis  .....       18 

Flint  on  Respiratory  Organs  ...        18 

Flint  on  the  Heart         .....       18 

Flint's  Essavs       ......        18 

Flint's  Practice  of  Medicine  ...       14 

Folsom's  Laws  of  U.  S.  on  Custody  of  Insane   .       19 
Foster's  Physiologj-       .....         8 

Fothergill's  Handbook  of  Treatment       .  .       16 

Fownes'  Elementary  Chemistry      ...         9 
Fox  on  Diseases  of  llie  Skin  ....       26 

Frankland  and  Japp's  Inorganic  Chemistry     ,         9 
Fuller  on  the  Lungs  and  Air  Passages     .  .       18 

Gant's  Student's  Surgery       ....       20 

Gibney's  Orthopwdic'Surgery  .       20 

Gould's  Surgical  Diagnosis     .  .  .  .21,31 

Gray's  Anatomy     .        .  .  .  .  .5 

Greene's  Medical  Chemistry  ....         9 

Green'sPathology  and  Morbid  Anatomy  .       13 

Griftith's  Universal  Formulary       ...       12 
Gross  on  Foreign  Bodies  in  Air-Passages  .       18 

Gross  on  Impotence  and  Sterility    ...       25 
Gross  on  Urinary  Organs        .  .  .  .       25 

Gross  System  of  Surgerv        .  .  .  .       20 

Habershon  on  the  Abdomen  .  .  .       16 

Hamilton  on  Fractures  and  Dislocations  .       22 

Hamilton  on  Nervous  Disea.ses       ...       19 
Hare's  Practical  TlH-rai)emics         ...       11 
Hartshorne's  Anatomy  and  Physiology  .  .         6 

Hartshorne's  Conspectus  of  the  Med.  Sciences  .         3 
Hartshorne's  Essentials  of  Medicine         .  .       14 

Hermann's  Experimental  Pharmacology  .       11 

Hill  on  Syphilis  ......       25 

Hillier's  Handbook  of  Skin  Diseases        .  .       26 

Hoblyn's  Medical  Dictionary  ...        3 

Hodge  on  Women  .....       28 

Hoffmann  and  Power's  Chemical  Analysis       .       10 
Holden's  Landmarks    .....         5 

Holland's  Medical  Notes  and  Reflections  .       17 

Holmes'  Principles  and  Practice  of  Surgery     .       22 
Holmes' System  of  Surgery  .  .  ,22 

Horner's  Anatomy  and  Histology  .  .         6 

Hudson  on  Fever  .  ...         4 

Hutchinson  on  Syphilis  .  .  .  .25,31 

Hyde  on  the  Dise'ases  of  the  Skin    ...       26 
Jones  (C.  Handfield)  on  Nervous  Disorders       ,       19 


Juler's  Ophthalmic  Science  and  Practice 

King's  Manual  of  Obstetrics  . 

Klein's  Histology  .... 

Laiidis  on  Labor  .... 

La  Roche  on  Pneumonia,  Malaria,  etc.     . 

I^  Roche  oil  Yello^v  Fever    . 

Laurence  and  Moon's  Ophthalmic  Surgery 

Lawson  on  the  Eve,  Orbit  and  Eyelid 

Lea's  Chanters  I'rbin  Religious  Hlstorj*  of  Spain 

Lea  s  Studies  In  Church  History 

Lea's  Superstition  and  Force 

Lee  on  Syphilis 

Lehmann  s  Chemical  Physiology    . 

Leishmau's  Midwifery 

Lucas  oil  Diseases  of  the  Urethra   . 

Ludlow's  Manual  of  Examinations 

Lyons  on  Fe\  er   . 

Maisch's  Organic  Materia  Medica  . 

Marsh  on  the  Joints 

May  on  Disea.ses  of  Women    . 

Medical  News 

Medical  News  Visiting  List   . 

Medical  News  Physicians'  Ledger  . 

Meigs  on  Childbetl  Fever 

Miller's  Practice  of  Surgery    . 

Miller's  Principles  of  Surgery 

Mitchell's  Nervous  Diseases  of  Women   . 

Morris  on  Diseases  of  the  Kidney  . 

National  Dispensatory  .  .  . 

National  Medical  Dictionary 

Neill  and  Smith's  Compendium  of  Med.  Scl. 

Nettleship  on  Diseases  of  the  Eye  . 

Norris  and  Oliver  on  the  Ej'e 

Owen  on  Diseivses  of  Children 

Parrish's  Practical  Pharmacy 

Parry  on  Kxtra-Uleriue  Pregnancy 

Parvin's  Midwifery  .... 

Pavy  on  Digestion  and  Its  Disorders 

Payne's  Otneral  Pathology    . 

Pepper's  System  of  Medicine 

Pepper's  Forensic  Medicine   . 

PeiJper's  Surgical  Pathology 

Pick  on  Fractures  and  Dislocations 

Pirrie's  System  of  Surgery    . 

Playfair  on  Nerve  Prostration  and  Hysteria 

Playfalr's  Jlidwifery     .... 

Politzer  on  the  Ear  and  its  Diseases 

Power's  Human  Phvsiolog}-  . 

Purdyon  Bright's  Di.seaseand  Allied  A  flections 

Ralfe's  Clinical  Chemistry 

Ramsbotham  on  Parturition 

Remsen's  Theoretical  Chemistry    . 

Reynolds' System  of  Medicine 

Richardson  s  Preventive  Medicine 

Roberts  on  Uriuar\-  Diseases  .  • 

Roberts'  Compend  of  Anatomy     .  . 

Roberts'  Surgery  .... 

Robertson's  Physiological  Physics  . 

Ross  on  Nervous  Diseases 

Savage  on  Insanity,  including  Hysteria  ■ 

Schafer's  Essentials  of  Histology, 

Schreiber  on  Massage   . 

Seller  on  the  Throat.  Nose  and  Naso-Pharynx 

Senn's  Surgical  Bacteriology 

Series  of  Clinical  Manuals 

Simon's  Manual  of  Chemistry 

Slade  on  Diphtheria      .... 

Smith  (Edward)  on  Consumption   . 

Smith  (J.  Lewis)  on  Children 

Smith's  Operative  Surgery     . 

.StlUe  on  Cholera  .... 

Stilie  &  Maisch's  National  Dispensatory 

Stillg's  Therapeutics  and  Materia  Medica 

Stimson  on  Fractures  and  Dislocations 

Stimson's  Operative  Surgery 

Students' Series  of  Manuals  . 

Sturges'  Clinical  Medicine 

Tait's  Diseases  of  Women  and  Abdom.  Surgery 

Tanner  on  Signs  and  Di.seases  of  Pregnancy 

Tanner's  Manual  of  Clinical  Medicine     . 

Taylor's  Atlas  of  Venereal  and  Skin  Diseases 

Taylor  on  Venereal  Diseases 

Taylor  on  Poisons 

Taylor's  Medical  Jurisprudence 

Thomas  on  Diseases  of  Women 

Thompson  on  Stricture 

Thompson  on  Urinary  Organs 

Tidy's  Legal  Medicine . 

Todd  on  Acute  Diseases 

Treves'  Manual  of  Surgery    . 

Treves'  Surgical  Applied  Anatomy 

Treves  on  Intestinal  Obstruction     . 

Tuke  on  the  Influence  of  Mind  on  the  Body 

Vaughan  &  Novy's  Ptomaines  and  Leucomaln 

Visiting  XJst,  The  Medical  News     . 

Walshe  on  the  Heart    .... 

Watson's  Practice  of  Physic  . 

Wells  ou  the  Eye  .... 

West  on  Diseases  of  Women 

West  on  Nervou-s  Disorders  in  Childhood 

Williams  on  Consumption     . 

Wilson's  Handbook  of  Cutaneous  Medicine 

Wilson's  Humau  Anatoniv   . 

Winckel  on  Pathol,  and  Treatment  of  Childbed 

Wohler's  Organic  Chemistr3- 

Woodhead's  Practical  Pathology    . 

Year-Books  of  Treatment  for  1886.  '87, 

Yeo  on  Food  in  Health  and  Disease 


23 
29 
1.1,31 
90 
18 
14 
23 
23 
31 
31 
31 
25 
8 
80 
24,31 
3 
14 
11 
21,31 
28 
1 
8 
8 

29 

21 

21 

19 

24,31 

12 

4 

3 

23 

23 

30,31 

11 

29 

29 

17 

13 

15 

31 

13,31 

22,31 

21 

19 

29 

23 

8.31 

24 

10,31 

28 

10 

14 

17 

24 

7 

20 
7,31 
19 
19,31 
13 
17 
18 
13 
4 
8 
18 
18 
30 
22 
14 
12 
11 
22 
22 
4 
17 
28 
29 
16 
28 
'25 
31 
31 
27 
24 
24 
31 
17 
21 
6,31 
21,31 
19 


es 


16 
3 
18 
14 
23 
28 
30 
18 
26 
6 
29 
8 
13 
and  '90  17 
.  17.31 


LEA    BROTHERS    &    CO.,    Philadelphia. 


